Every finding on record at Washington Healthcare Center

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, comfortable, and homelike environment for 7 of 7 residents who had observed concerns (Residents 40, 10, 12, 5, 47, 20, and 51).Findings include:1. On 8/6/25 at 10:10 a.m., Resident 40's call light was observed out of reach, wrapped on top of the bedside dresser. The cord was visibly dirty with stains and built-up debris under peeling tape. On 8/8/25 at 10:00 a.m., Resident 40's call light remained out of reach, hung over the call box on the wall. The cord remained dirty. On 8/11/25 at 9:31 a.m., Resident 40's call light was observed hung out of reach on the call box, the cord remained dirty. On 8/12/25 at 10:25 a.m., Resident 40's call light remained out of reach and rested on the floor. The yellow tape was still peeling and there was stuck on debris. There were several gnats flying around his head and in the bathroom. 2. On 8/6/25 at 10:29 a.m., Resident 10's fall mattress on the floor beside his bed was observed dirty, stained, and had visible food crumbs and other unidentifiable substances on it. The wall beside his bed was dirty with visible stains and smears. On follow up observations on 8/7/25 and 8/8/25, Resident 10's wall and fall mattress remained dirty. On 8/8/25 at 10:44 a.m., Resident 12's bed was stripped of linen, the mattress surface was observed to be peeling with a large central stain, and discoloration around the edges. The wall beside the bed was streaked with stains. On multiple observations as timestamped above, Resident 40's bedside table was observed to have a dirty and stained surface, the legs of the table were also visibly dirty with unidentifiable clumps and streaks of debris. On 8/6/25 at 12:01 p.m., 8/7/25 at 9:09 a.m., and 8/8/25 at 10:48 a.m., Resident 5's Tube Feeding pole was observed. The equipment was broken as evidence by missing a rolling wheel on one of the legs, which caused the pole to lean to one side and wobbled. There was no metal shine on the length of the pole as it was streaked, stained and clumped with unidentifiable debris. Resident 5's bed frame was observed to have spilled and dried clumps of feeding. There were several gnats flying throughout her room during these observations. 3. On 8/6/25 at 10:12 a.m., Resident 47's fitted bed sheet was observed to be worn thin, the material sheer enough to see the mattress details under the sheet. Some areas were streaked thin enough that small holes had developed. On 8/6/25 at 11:41 a.m., Resident 20's bed was observed. There was a folded blanket in the middle of the bed, but the edges were frayed and tattered. During an interview on 8/6/25 at 11:46 a.m., Resident 51 indicated they were always out of linen, especially fitted sheets, and the linen they had were worn and dingy. 4. On 8/6/25 at 10:18 a.m., room [ROOM NUMBER]'s bathroom had a non-skid tape strip that had completely detached from the floor and was curled on the floor at the base of the toilet. The grab rail was covered in yellow tape with smeared feces visible on the tape. A strong odor was present. On 8/7/2025 at 10:06 a.m., room [ROOM NUMBER]'s bathroom was observed. The non-skid tape remained peeled and curled on the floor and the smeared stain of feces still on the yellow tape of the grab bar. On 8/8/25 at 10:41 a.m., room [ROOM NUMBER]'s bathroom remained uncleaned. The peeled and curled non-skid strip remained on the floor and the grab bar wrapped in yellow tape remained visibly stained. 5. On 8/06/25 at 10:49 a.m., Resident 5's tube feeding and hydration kangaroo bags were left uncapped and open to the air. There were several gnats observed flying through the room. On 8/6/25 at 12:03 p.m., the 300-hall meal cart was [NAME] to the floor. Beverages had not been pre-prepared and were poured while on the hall. The cups of milk and juices were not covered after they were filled and placed on trays, and there were several gnats flying through the hallway. On 8/11/25 at 9:31 a.m., several, more than 5, gnats were observed on the rim of a milk cup left on Resident 40's bedside table. There were several cups uncovered as the gnats continued to fly around the cups, the resident's head, and the bedside table. On 8/11/25 at 2:15 p.m., an environmental tour was conducted with the Regional Director of Clinical Services (RDCS). Resident 40, Resident 5, Resident 10, and the bathroom for room [ROOM NUMBER] were visited. The RDCS indicated the areas of concern would be addressed. On 8/11/25 at 2:00 p.m., the RDCS indicated there was no policy for a Clean/Comfortable/Homelike Environment, but indicated the residents had the right to live in healthy, clean, and comfortable environments. At that time, she provided a copy of current, but undated, facility policy for Resident's rights titled, Your Rights and Protections as a Nursing Home Resident. The policy indicated, .at a minimum, Federal law specifies that nursing homes must protect and promote the following rights of each resident. you have the right to be treated with dignity and respect. 3.1-19(f)

Based on observations, interviews, and record review, the facility failed to ensure proper oral hygiene was provided and maintained for a dependent resident (Resident 5) and failed to ensure a resident preference for facial hair was maintained (Resident 49) for 2 of 4 residents reviewed for Activities of Daily Living.Findings include:1.On 8/6/25 at 10:49 a.m., Resident 5 was observed. She laid in her bed and had a Tube Feeding hung and running. Her lips were dry and cracked, there was a pasty/frosty build-up around her lips and gums. On 8/6/25 at 12:02 p.m., Resident 5's was observed. Her lips remained dry and cracked, and there was a thick build-up of pasty drying secretions. There was an uncovered cup of blue liquid and an oral sponge left on her bedside table. There were two gnats on the rim of the cup. On 8/7/25 at 9:09 a.m., Resident 5 was observed. Her lips were dry and cracked, and a thick layer of pasty secretions rimmed her lips and gums. Her teeth were also observed to have built up plaque/tarter. On 8/8/25 at 10:17 AM Resident 5 was observed. Her mouth remained in need of oral care as evidence by dry cracked lips and a buildup of frothy, pasty secretions. During an interview on 8/8/25 at 1:47 p.m., Certified Nursing Aide (CNA) 6 indicated they did not like to use a toothbrush for Resident 5 because it caused his gums to bleed. Instead, they used an oral swab dipped in mouthwash to clean out her mouth. On 8/8/25 at 1:31 p.m., Resident 5's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, cerebral palsy, severe intellectual disabilities and Down Syndrome. She required the use of a gastrostomy tube (G-tube) and had a physician's order not to receive anything by mouth (NPO). Resident 5 had a comprehensive care plan, initiated 1/15/24, which indicated, she .has likely cavity teeth and is at risk for further impairment due to NPO status. Interventions for this plan of care included, but were not limited to, assist resident with oral care, dental consult as indicated, observe and document: red/bleeding gums, lesions, loose teeth, symptoms of pain, and notify MD. Resident 5 had a dental exam on 4/28/25. The exam notes indicated, Tissues are red and inflamed. Heavy plaque, poor oral hygiene. Oral Hygiene Instructions: Brush 2x/daily. Generalized worn teeth. Dry mouth noted. Resident 5 had a dental exam on 5/28/25. The exam notes indicated, moderate plaque, heavy build up and severe gingivitis along gumline. Staff needs to try and use brush along gumline for as long as patient will allow due to bleeding/gingivitis present with severe build up. The record lacked documentation that oral care had been completed, if the resident was cooperative or refused, and/or attempts were made to brush her teeth. On 8/8/25 at 2:04 p.m., the Regional Director of Clinical Services (RDCS) indicated there was no specific policy for oral care but provided a list of tasks for a.m. routine cares which should be completed by the CNAs for each resident as applicable. The AM care included, but were not limited to, .step 7. Assist resident with oral hygiene. 2. On 8/6/25 at 10:25 a.m. Resident 49 was observed as he lay in bed resting. He appeared to be unkempt; his beard and hair appeared to be overgrown. Resident 49 indicated several times he was very upset that he hadn't been shaved or had a haircut in over two weeks. He indicated he normally kept his face clean shaven. On 8/11/25 at 10:43 a.m. Resident 49 was observed as he lay in bed resting with his eyes closed. The resident's hair and beard did not appear to have been trimmed at that time. On 8/12/25 at 10:32 a.m. Resident 49 was observed as he sat in a chair waiting for a doctor's appointment. His hair and beard had not been trimmed at this time. On 8/12/25 at 9:40 a.m. Resident 49's medical record was reviewed. He was a long-term care resident residing on the memory care unit whose diagnoses included but were not limited to dementia and osteoarthritis (a degenerative joint disease characterized by the breakdown of cartilage and the underlying bone in a joint.). Resident 49's last Brief Interview for Mental Status (BIMS) (A cognitive screening tool used to assess cognitive function, primarily in nursing homes and long-term care facilities) score was 8 out of 12 which indicated moderate cognitive impairment. A progress note, dated 8/2/25 at 7:57 p.m., indicated Resident 49 required assistance of one staff member for Activities of Daily Living (ADL). During an interview on 8/12/25 at 1:20 p.m., Regional Director of Clinical Services (RDCS) indicated she knew his preference was to be clean shaven and she had offered to shave him herself and had other staff offer, but he only wanted a professional barber or beautician to shave him and cut his hair. She and the Executive Director (ED) both agreed that they could get Resident 49 to a barber, there isn't a beautician in the facility at this time, but they could attempt to take him to a sister facility or a barber shop or have a beautician from a sister facility come to shave him. The record lacked documentation related to arranging to take Resident 49 to a barber or beautician as of 8/12/25 at 1:20 p.m. On 8/8/25 at 2:04 p.m., the RDCS indicated there was no specific policy for oral care but provided a list of tasks for a.m. routine cares which should be completed by the CNAs for each Resident as applicable. The AM care included, but was not limited to, .8. Shave resident, if needed or requested. 3.1-38(a)(3)

Based on observations, interviews, and record reviews, the facility failed to provide appropriate, person centered programing, and treatment plans to attain or maintain the highest practical level of psychosocial well-being for 1 of 5 residents (Resident 11) reviewed for behavioral health concerns.Findings include:On 8/6/25 at 10:50 a.m. Resident 11 was observed as she lay in bed watching her roommate's tv and resting. There was no tv on her side of the room. Resident 11 indicated she arrived at the facility about 5 months ago and hadn't had any problems so far. She appeared to have a flat affect (a severe reduction in the outward expression of emotion) and a low mood.On 8/7/25 at 9:45 a.m. the memory care unit dining room was observed. There were three residents at a table with the Dementia Care Facilitator watching a cooking show on a tablet and two residents sitting on the couch watching TV. This was not the scheduled activity.On 8/7/25 at 12:01 p.m. Resident 11 was observed in bed resting with her eyes closed.On 8/7/25 at 12:15 p.m. Resident 11 came out to the dining room for lunch. On 8/7/25 at 12:45 p.m. Resident 11 went back to her room after lunch.On 8/8/25 at 10:42 a.m. the memory care dining room was observed. There were six residents listening to soothing music and having a snack.On 8/8/25 at 11:00 a.m. the Memory Care Facilitator began playing a trivia game with the residents. This was not the scheduled activity.On 8/8/25 at 11:28 a.m. Resident 11's medical record was reviewed. She was a long-term care resident residing on the memory care unit whose diagnoses included but were not limited to Schizophrenia and history of a traumatic brain injury.A progress note, dated 3/25/25 at 4:35 p.m., indicated Resident 11 was admitted to the facility in a long-term care bed due to a fall.A progress note, dated 3/27/25 at 1:58 p.m., indicated Resident 11 attempted to leave the facility. She indicated a family member was at the front door to pick her up, but no one was there for her.A provider note, dated 4/10/25 at 7:06 a.m., indicated Resident 11 reported her mood had improved and she felt less sad, depressed, and anxious.A progress note, dated 4/11/25 at 12:33 a.m., indicated Resident 11 had packed her bags and requested to leave. The writer of the note explained the resident could not leave and the resident understood and did not try to leave.A behavioral note, dated 4/17/25 at 3:44 p.m., indicated Resident 11 was experiencing delusions and hallucinations. The intervention attempted was to assist the resident in calling her daughter, which was successful.A Medicare charting note, dated 4/21/25 at 10:28 p.m., resident was tearful at times but was easily redirected.A provider note, dated 4/24/25 at 6:33 a.m., indicated Resident 11 wanted to leave the facility, but there had been no elopement attempts.A progress note, dated 5/27/25 at 9:47 p.m., indicated Resident 11 was having delusional thoughts and hallucinations, but she was easily redirected back to her room.A progress note, dated 6/5/25 at 4:36 p.m., indicated Resident 11 was seen walking the halls, appeared to be tearful, and had many questions but was easily redirected.A progress note, dated 6/11/25 at 2:09 p.m., indicated Resident 11 started packing her clothes and taking them to the front door stating her brother was outside waiting for her. The resident was redirected back to her room.A progress note, dated 6/19/25 at 1:32 p.m., indicated Resident 11 was moved to the memory care unit.A progress note, dated 6/19/25 at 9:10 p.m., indicated Resident 11 was in her room crying and talking loudly, a staff member went in and the resident calmed down but after the staff member left the resident began crying again. The note indicated the resident asked repeatedly to go to the main lobby door so that her family can be let into the building, the staff member told the resident that if her family was here, they would be directed to the memory care unit. The resident did not like that answer, she yelled and went back to her room.A behavior note, dated 6/21/25 at 12:23 p.m., indicated Resident 11 had an episode of tearfulness and hallucinations. The note indicated the resident was able to talk to her daughter on the phone and that calmed her down.A progress note dated 7/2/25 at 9:07 a.m. indicated Resident 11 became upset after she requested to go outside of the unit for activities and to play bingo and have snacks with everyone else when the Activities Director was on the unit. The note indicated the resident was offered activities on the unit but the resident refused.A progress note, dated 7/29/25 at 11:51 a.m., indicated Resident 11 had a visit from her ex-boyfriend and some family members.A behavioral IDT note, dated 7/30/25 at 10:34 a.m., indicated Resident 11 was stating her daughter was at the facility to pick her up. The resident stated staff can't see her daughter. Resident 11 started yelling out loudly, crying and banging on the door to be let out. The immediate intervention was to offer snacks and drinks to the resident, but the resident refused. Staff also assisted the resident in calling her daughter, which was successful. The preventative intervention was to redirect the resident to activities like watching tv and assist in calling her daughter when time permits.A provider note, dated 7/31/25 at 6:54 a.m., indicated Resident 11 was adjusting to the memory care unit fair. The provider indicated Resident 11 complained of feeling anxious.A progress note dated 8/3/25 at 5:49 p.m. indicated Resident 11 was seen banging on the exit door repeatedly.A preferences for customary routine and activities assessment dated [DATE] indicated Resident answered the question, . While you are in this facility how important is it to you to be able to use the phone in private? ., with somewhat important.Resident 11's activity log for July was reviewed. Activities were logged three times that month.Resident 11's activity log for August was reviewed. Activities had been offered 8 times so far.On 8/5/25 at 10:08 a.m. Resident 11 was invited to do popsicle stick crafting, the resident refused.On 8/7/25 at 11:19 a.m. Resident 11 was invited to bake chocolate chip cookies, the resident refused.On 8/7/25 at 11:27 a.m. Resident 11 was invited to chair yoga, the resident refused.On 8/7/25 at 11:35 a.m. Resident 11 was invited to a ted-talk and morning discussion, the resident refused.On 8/7/25 at 11:53 a.m. Resident 11 was invited to play a ball toss game, the resident refused.On 8/11/25 at 11:38 a.m. Resident 11 was invited to go outside and get some fresh air, the resident refused.During an interview on 8/11/25 at 10:43 a.m., Resident 11 indicated she liked it much better out in the long-term care section of the facility. She indicated she felt like all she did was lay in bed because there weren't many activities on the memory care unit that interested her. Resident 11 indicated she used to be able to make private phone calls from her room when she was in the long-term care side but now, she can only make calls from the front desk.On 8/12/25 at 11:45 a.m. the Social Services Director (SSD) provided a current facility policy titled, Activities, dated 1/06. This policy indicated, . it is the policy of this facility to provide for an ongoing program of activities designed to meet the interest and the physical, mental and psychosocial well-being of each resident in accordance with the comprehensive assessment.3.1-373.1-43

Based on observation, interview, and record review, the facility failed to ensure a vegetarian resident had food variety and options to meet his dietary preferences for 1of 1 resident reviewed for dietary preferences (Resident 43). Findings include:On 8/6/25 at 11:00 a.m. Resident 43 was observed as he sat on his bed. The resident indicated the food the facility provided was terrible. He indicated sometimes he could send the food back and they gave him something else but a lot of times there wasn't anything for them to give him because he was vegetarian. He indicated most days he got either grilled cheese or a peanut butter and jelly sandwich for his entree.On 8/7/25 at 12:17 p.m. lunch trays were observed being passed to residents in the memory care dining room. Resident 43 received two grilled cheese sandwiches and two sides.On 8/12/25 at 9:40 a.m. Resident 43's medical record was reviewed. He was a long-term care resident residing on the memory care unit whose diagnoses included but were not limited to traumatic brain injury (TBI) and depression. His diet order indicated he was on a regular diet and he was a vegetarian.A progress note, dated 4/24/25 at 3:48 p.m., indicated Resident 43's sister talked with the Registered Dietician and indicated the resident had been a vegetarian for 17 to 18 years. She indicated he loved pizza, Asian, Thai, Indian foods, fruit, grains, vegetables, etc. She also indicated he liked meatless products and other faux meat products.On 8/12/25 at 10:44 a.m. the Culinary Director provided meal tickets for Resident 43 from 8/5/25 to 8/12/25.On 8/5/25 Resident 43's entrees for breakfast, lunch, and dinner were scrambled eggs, grilled cheese sandwich, and peanut butter and jelly.On 8/6/25 Resident 43's entrees for breakfast, lunch, and dinner were cheesy eggs, peanut butter and jelly, and pasta with no meat (cheese, noodles, and sauce).On 8/7/25 Resident 43's entrees for breakfast, lunch, and dinner were scrambled eggs, cheese and fruit plate, and kidney beans with onion, celery and tomato sauce.On 8/8/25 Resident 43's entrees for breakfast, lunch, and dinner were scrambled eggs, grilled cheese, and peanut butter with crackers.On 8/9/25 Resident 43's entrees for breakfast, lunch, and dinner were cheesy eggs, peanut butter sandwich, and soup with kidney beans.On 8/10/25 Resident 43's entrees for breakfast, lunch, and dinner were scrambled eggs, cheese and crackers, and bean burrito.On 8/11/25 Resident 43's entrees for breakfast, lunch, and dinner were egg muffin sandwich, grilled cheese, and peanut butter and jelly with tomato soup.On 8/12/25 Resident 43's entrees for breakfast, lunch and dinner were scrambled eggs, peanut butter and celery, and cheese crackers.During an interview on 8/11/25 at 11:15 a.m. LPN 7 indicated Resident 43 is a vegetarian and they were doing the best they could to get him appropriate meals, but there could have been more options for him. 3.1-21(a)(4)

Based on record reviews and interviews, the facility failed to offer the influenza (flu) vaccination to 2 of 5 residents reviewed for the influenza vaccination (Resident 11 and 18). Findings include:1. On 8/11/25 at 1:39 p.m., a record review was completed for Resident 11. She had the following diagnoses which included, but were not limited to, Schizophrenia, asthma, and sleep apnea. Her record lacked a consent to receive the influenza vaccination, and she did not receive the vaccination. 2. On 8/11/25 at 1:44 p.m., a record review was completed for Resident 18. He had the following diagnoses which included, but were not limited to, dementia, type 2 diabetes mellitus, chronic kidney disease, and anxiety. His record lacked a consent to receive the influenza vaccination, and he did not receive the vaccination. On 8/11/25 at 2:00 p.m., during an interview with the Regional Clinical Specialist (RCS), she indicated she could not find the consents or where the residents were administered the vaccinations. A policy titled, Influenza (Flu) Vaccination (Resident) was provided by the RCS on 8/12/25 at 10:55 a.m. It indicated, .Current and newly admitted residents will be offered the influenza vaccine, unless the immunization is contraindicated, or the resident has already been immunized during this times period (unless otherwise recommended by the Centers for Disease Control and prevention (CDC).

Based on record review and interview, the facility failed to offer a resident the COVID-19 vaccination for 1 of 5 residents reviewed (Resident 15). Findings include:On 8/11/25 at 1:32 p.m., a record review was completed for Resident 15. She had the following diagnoses which included but were not limited to Alzheimer's disease, hypertension, major depression, and anxiety. Her record lacked a consent to administer the COVID-19 vaccinations, and lacked documentation the COVID-19 vaccination was administered.On 8/11/25 at 2:00 p.m., during an interview with the Regional Clinical Specialist (RCS), she indicated she could not find the consent or where the resident was administered the COVID-19 vaccination.A policy titled, Resident COVID-19 Vaccination was provided by the RCS on 8/12/25 at 10:55 a.m. It indicated, .On admission resident(s) will be offered the COVID-19 vaccinations based on their COVID-19 vaccination history.

Based on interview and record review, the facility failed to complete a physician's order to change a peripherally inserted central catheter (PICC) line for 1 of 3 residents reviewed for neglect. (Resident D) Findings include: The clinical record for Resident D was reviewed on 5/23/25 at 11:25 a.m. Diagnoses included colostomy infection, osteomyelitis, diabetes mellitus type II, and necrotizing fascititis. The resident admitted to the facility from an acute care hospital on 3/20/25. An admission Minimum Data Set (MDS) assessment, dated 3/27/25, indicated the resident had moderate cognitive impairment, had no behaviors or rejection of care, had an indwelling catheter and an ostomy, had an unstageable pressure ulcer, and received intravenous medications. A physician's order, received 3/20/25, indicated to change the peripherally inserted central catheter (PICC) dressing every seven days with a transparent dressing. The nurse needed to measure (in centimeters) the PICC catheter length (from insertion site to catheter hub) AND the nurse needed to measure upper arm circumference (10 cm above antecubital fossa). The resident's electronic treatment administration report (eTAR) for March, lacked documentation the resident's PICC line dressing had been changed and measurements completed per physician's order. During a telephone interview on 5/27/25 at 2:25 p.m., the social worker from the acute care hospital the resident was transferred to on 3/28/25, indicated the resident's PICC line inserted in the resident's upper right arm, had a dressing over it, dated 3/19/25. The dressing had not been changed at the skilled care facility. During an interview on 5/24/25 at 1:48 p.m., the DON indicated she was not aware the PICC dressing was not changed on the 3/27/25 per physician's order. The order was to be completed sometime between 11:00 p.m. on 3/27/25 and 6:00 a.m. on 3/28/25. The resident's clinical record included multiple notes documenting the dressing was clean, dry, and intact, but no indication of the dressing being changed. The PICC dressings were to be changed every seven days. A current facility policy, revised 1/15/2004, titled, Central Vascular Access Device (CVAD) Dressing Change, provided by the DON on 5/27/25 at 11:56 a.m., indicated the following: .Considerations . Central vascular access devices (CVADs) include: 1.1 Peripherally inserted central catheter (PICC) .Guidance. 1. Perform sterile dressing changes . Upon admission .If transparent dressing is dated, clean, dry, and intact, the admission dressing change may be omitted and scheduled for 7 days from the date on the dressing label . Upper arm circumference with PICC, and external catheter length measurements must still be completed as part of the initial assessment 9. Length of external catheter is obtained .Upon admission 10. For PICCs, upper arm circumference (10 cm above antecubital fossa) is obtained Upon admission if no insertion measurement available, then weekly This citation relates to Complaint IN00456604. 3.1-37(a)

Based on observations, interviews and record reviews, the facility failed to ensure Resident Council Grievance concerns related to call light wait and response times were addressed in a timely and effective manner to prevent ongoing concerns. This deficient practice had the potential to affect 10 of 53 residents who attended the Resident Council Meeting and complained on behalf of all 53 residents who resided in the facility. Findings include: On 7/9/24 at 9:36 a.m., the call light for room [ROOM NUMBER] was observed. It was illuminated, flashed and alarmed at the nurse's station. Several staff members passed the light. On 7/10/24 at 11:00 a.m., Resident 35 was heard as she yelled out, Nurse! over and over. After five minutes, Resident 35 yelled again, with a louder voice and frustrated tone. This visitor knocked and entered her room to ask what the resident needed assistance with. Resident 35 indicated she wanted to get out of bed, but no one would listen to her. Within seconds of the visitor's entrance into the room, 4 staff members came to answer the light. On 7/10/24 at 11:28 a.m., Resident 12's call light was illuminated, flashed and sounded at the nurses' station. After more than 5 minutes, this visitor knocked and asked the resident what she needed assistance with. The resident indicated she was still waiting for her morning medications. During the interview, the Executive Director (ED) entered the room to take over her concern. On 7/10/24 from 11:37 a.m. until 11:43 a.m., the call light for room [ROOM NUMBER] was illuminated, flashed and sounded at the nurses' station. Two nurses stood at the medication cart one door down from the illuminated call light and carried on a personal conversation. This visitor saw two Certified Nursing Aides, (CNAs) who came up the hall and asked if room [ROOM NUMBER]'s light had been answered. One unidentified CNA indicated; they were on the way to address it at that time. On 7/10/24 at 11:43 a.m., the call light for room [ROOM NUMBER] turned on. Two nurses were sitting at the nurses' station. The alarm at the nurses' station continued for over 5 minutes before the ED came to the nurses' station and asked someone to answer the light. At 11:52 a.m., one of the nurses took a glass of ice to the room and turned off the light. On 7/11/24 at 9:16 a.m., room [ROOM NUMBER]'s bathroom call light was observed illuminated and sounded for over 5 minutes. This visitor knocked and entered to ask the resident what she needed assistance with and found the resident on the toilet. At that time, the ED came to take over the concern. On 7/11/24 at 12:49 p.m., the call light for room [ROOM NUMBER] was observed illuminated and alarmed for over 5 minutes. There were two nurses at the desk who did not get up to answer the light until this visitor knocked and entered the room. On 7/10/24 at 1:20 p.m., the Resident Council Minutes were reviewed and revealed the following. A meeting was held on 4/5/24 and 11 residents were present. They complained that call light response time was too long, night shift concerns for call lights. A Follow-Up response form dated 4/5/24 indicated education and in-service was provided to staff to answer call lights on time. A meeting was held on 4/26/24 and 7 residents were in attendance. They complained that call light response time was improved, but they still waited a long time. A meeting was held on 5/3/24 and indicated, concerns identified during the previous meeting, call lights not answered promptly. A Follow-Up form dated 5/3/24 indicated staff had been educated on answering call lights promptly. A meeting was held on 7/5/24 and 8 residents were in attendance. They complained, half an hour up to an hour [call light] wait time. A Follow-Up form dated 7/8/24 indicated education was provided to the staff to address call light wait times. Records of the above-mentioned education/in-service records were requested and provided by the Regional Director of Clinical Services (RDCS) on 7/10/24 at 1:50 p.m. The In-Service binder was reviewed. Although there were various attendance sheets with staff signatures and a summary of the meeting, there was no accompanying documentation of what was reviewed, how it was reviewed, and/or additional education or training for ineffective in-services. Additionally, there were several attendance logs with signatures, but no summary or title of the in-service. On 7/10/24 at 2:00 p.m., the RDCS indicated, the previous Director of Nursing (DON) had been responsible for the implementation and organization of the Facility's In-Service Program, but evidently had not kept up with the documentation. No additional documentation could be provided. On 7/11/24 at 1:00 p.m., the RDCS provided a copy of the current facility policy titled, Resident Council, dated 2/2020. The policy indicated, The facility will promote and support the resident's right to participate and organize resident council. The council will be used to communicate concerns, give suggestions for future programming and events, and otherwise participate in and guide facility life . concerns or suggestions from the meeting will be addressed by the appropriate department. The Executive Director will review all minutes and concerns to ensure thorough resolution of concerns 3.1-3(k)

Based on observation, interviews and record reviews, the facility failed to ensure a resident (Resident B) was treated with respect and dignity during a care plan meeting when she attempted to express her concerns for 1 of 3 residents reviewed for dignity. Findings include: On 7/8/24 at 10:16 a.m., Resident B was observed as she reclined in her bed and played a game on her smartphone. During a general and initial interview, Resident B indicated the Executive Director (ED) had hurt her feelings and made her angry. Resident B indicated she did not feel comfortable talking about the ED and was afraid she would get in trouble if she continued to complain about the way she felt she had been treated. Resident B indicated, she had been in a care plan meeting with the Social Service Director, the Minimum Data Set Coordinator (MDSC) and her best friend who helped her coordinate her care was on speakerphone. During the meeting, the ED had been asked to come to the room since Resident B and her friends had several additional care concerns that needed to be addressed. When the ED came and got involved in the conversation, she said something that offended Resident B. When Resident B attempted to inform her of the offense, she addressed the ED by saying, hey you, but before she could finish, the ED cut her off and pointed her finger in her face and said, excuse me, I am not a 'you' I'm a person and you will treat me with respect. Resident B was astonished and told the ED back, you'll have to earn my respect. Then the ED replied, I don't feel much like respecting you at all. After that, the ED abruptly ended the care plan meeting and told the MDSC and SSD to leave the room and the ED left too. Resident B indicated the door was slammed on the way out, and she was speechless. She cried from embarrassment and anger and finished talking with her friend who helped calm her down. During a confidential interview, it was indicated, a verbal altercation was overheard between Resident B and the ED. Resident B had not known or had not remembered the ED's name because the ED was relatively new to the building. When Resident B addressed the ED as you, she had not done so with negative intentions, but she just didn't know the ED's name. It was indicated, the tone and attitude of the ED's voice was much more aggressive than appropriate and it was unprofessional to argue, end the meeting, and slam the door. During a confidential interview, it was indicated, Resident B was a unique character with several personality quirks and oddities. When someone talked to Resident B, they would need to be patient as she tended to go on tangents and get sidetracked with unrelated topics/stories. Resident B had some cognitive/intellectual impairments that sometimes made her sound and act childish, but overall, she was a cooperative and pleasant resident who had a good rapport with most of the staff members and even gave them little gifts like snacks and candy. With her oddities, Resident B was sometimes misunderstood and would snap back at people, but if the person was patient, Resident B would come back around and apologize. Staff members who knew Resident B, knew not to take it seriously or personally. The ED, however, was new to the building and did not know Resident B very well. During a recent care plan meeting, Resident B addressed the ED as you and used a backscratcher to point at the ED to address her, and the ED took great offense to it. The ED interrupted Resident B, pointed back at her, and with a disrespectful tone told her to treat her with respect. Resident B indicated she also deserved respect, but the ED replied that she did not feel like Resident B deserved respect. The ED ended the meeting and made everyone leave. During an interview on 7/10/24 at 11:00 a.m., Resident B's friend indicated, she had been on speakerphone during the care plan meeting and requested the ED to come and address several of her concerns. Resident B's friend had concerns related to her wound treatment changes and medication regimen. During the conversation, the ED raised her voice at Resident B and demanded that Resident B treat her with more respect than she had. Resident B became upset and tearful. Resident B's friend indicated her actions had been very unprofessional. During a confidential interview, it was indicated, someone went in to check on Resident B, as they routinely did when they were there. They found Resident B crying, which was odd, as Resident B was usually very pleasant and jovial. Resident B retold the story of the incident where the ED had been rude and disrespectful to her and made Resident B feel like she did not matter. During an interview on 7/11/24 at 11:42 a.m., the ED indicated, she had been asked to come down to a care plan meeting for Resident B because the resident and her representative had many care concerns that needed to be addressed. The ED indicated she did not remember what led up to the incident, but Resident B had been using foul language and was being disrespectful to her and the staff. At one-point, Resident B held up her backscratcher in an aggressive manor and pointed it into the ED's face and called her, you. The ED indicated she had been offended and felt demeaned, so she told Resident B, to get respect you have to earn respect. The ED ended the care plan meeting because they were not getting anywhere productive, and she did not remember slamming the door. On 7/10/24 at 10:55 a.m., Resident B's medical record was reviewed. She was a long-term care resident who had diagnoses which included but were not limited to mild cognitive impairment, dementia and depression. The most recent minimum data set (MDS) assessment was a quarterly assessment dated [DATE] which indicated Resident B was cognitively intact and had no behaviors coded for the look-back timeframe. Resident B's care plan was reviewed and lacked documentation or revision of a history or risk of behaviors related towards staff. Resident B's observations and events lacked documentation of behavioral concerns related towards staff. During the survey entrance conference on 7/8/24 at 9:30 a.m., a copy of the facilities' Residents Rights policy was requested and provided by the ED. The policy was titled, American Senior Communities Resident's Rights, revised 10/2023. The policy indicated, The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident .The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States, and to be free from interference, coercion, discrimination, and reprisal from the facility . The resident has the right to be treated with respect and dignity This citation relates to Complaint IN00433695. 3.1-3(t)

Based on observations, interview, and record review, the facility failed to ensure a resident, (Resident 3) was included and engaged in a meaningful activity program according to her routine and preferences to maintain and/or enhance her quality of life as a totally dependent resident for 1 of 3 residents reviewed for Activity Programming. Findings include: On 7/8/24 at 10:43 a.m., Resident 3 was initially observed in bed in her room. She wore a hospital gown, her hair was flattened on one side, and her lips and gums were observed to have a buildup of unidentified goopy debris. Her side of the room was darkened as the privacy curtain between her, and her roommate's side had been pulled so that the natural light from her roommate's window could not be viewed. The ceiling lights were off. Resident 3's TV was off, and there was no music. She was positioned in bed with the head of her bed (HOB) elevated as her tube feeding pump was hooked up and running. Resident 3 leaned on her left side, and her eyes were open, but she stared at a bare blank wall. There were no pictures, calendar, murals, mirrors etc., she clutched an old, naked baby doll. No other toys or stuffed animals were observed. She reached out her hand, and grasped firmly as she made a whimpering, crying tearful sound. At that time, her roommate, Resident 40 indicated, she cried a lot, sometimes it was real, sometimes it was for attention. Resident 40 indicated, staff almost never got her out of bed, and as far as Resident 40 knew, no one took her to activities either. Sometimes Resident 40 would play [NAME] music for her on her phone and Resident 3 liked to clap along to it. Resident 3 was observed in bed for the remainder of the day on 7/8/24. On 7/9/24 at 10:00 a.m., Resident 3 was observed as she remained in bed. The light in her room was off, the curtain was drawn, and her side of the room was darkened. She stared at the bare, blank wall. On 7/9/24 at 1:26 p.m., Resident 3 was observed as she remained in bed. The light in her room was off, the curtain was drawn, and her side of the room was darkened. She stared at the bare, blank wall. Resident 3 was in bed for the remainder of the day on 7/9/24. On 7/10/24 at 9:20 a.m., Resident 3 was observed. She remained in her bed in a hospital gown. The room was dark. Her roommate's TV was on, but hers was off. There was no music. There was no aromatherapy, and her baby doll was out of reach at the end of her bed. She stared at her bare, blank wall. On 7/10/24 at 12:09 p.m., the Activity Director (AD) indicated, she was newer to the building and had not been there a year yet. Since she started, she had been told, Resident 3 didn't get up very often, and when she went to check, Resident 3 was never dressed or gotten up to be brought down to activities. The AD indicated Resident 3 was on one-to-one activities. On 7/10/24 at 3:00 p.m., Resident 3 remained in bed. At that time, Laundry Assistant 16 entered Resident 3's room, and proceeded to put clothes away for Resident 3 and 40. Laundry Assistant 16 indicated she had worked at the facility for many years and knew Resident 3 very well. This was demonstrated as Laundry Assistant 16 approached Resident 3's bed, held her hand and gave her affectionate baby kisses on her cheek. Resident 3 smiled broadly, and wrapped her arm around the staff member's neck and did not want to let go. Laundry Assistant 16 indicated, Resident 3 used to get up every day and would always be in or around activities. She loved to hold hands, blow kisses, hug, and watch people come and go. She did not know why Resident 3 no longer got out of bed. Resident 3 was in bed for the remainder of the day on 7/10/24. On 7/11/24 at 10:03 a.m., Resident 3 was observed in bed. The light in her room was off, the curtain was drawn, and her side of the room was darkened. She stared at the bare, blank wall. During an interview on 7/11/24 11:09 a.m., the Regional Director of Clinical Services (RDCS) indicated, she did not know of any reason why Resident 3 should not be up on a routine basis. The RDCS indicated, Resident 3 had always enjoyed being up and socializing, despite her intellectual disability, she loved to engage with other residents and staff. During an interview on 7/11/24 at 11:56 a.m., the Executive Director (ED) indicated, since she had been at the facility, she had seen Resident 3 up every now and then, but she mostly stayed in bed. The ED indicated she did not know Resident 3 too well yet. When Resident 3's activity participation log was reviewed, the ED indicated there needed to be more variety and rotating 3 simple things and she would talk with the Interdisciplinary team (IDT) to establish a more meaningful and engaging routine and program for Resident 3. On 7/11/24 at 12:10 p.m., Resident 3's medical record was reviewed. She was a long-term care resident with diagnoses which included, but not limited to, cerebral palsy (a congenital disorder of movement, muscle tone, or posture), severe intellectual disability, and down syndrome. Resident 3's nursing progress notes between 1/1/24 and 7/11/24 were reviewed and revealed. There was a total of 36 entries. 8 entries noted that she was in bed, while only one indicated she had been gotten up in her chair. On 7/11/24 at 11:00 a.m., the RDCS provided a copy of Resident 3's activity participation logs for 6/1/24-7/11/24. There were three activities logged for the timeframe: 1. Resident enjoys listening to [NAME] channel/music in her room. 2. Resident enjoys calming music and lotion applied to her hands. 3. Resident enjoys cuddling with childlike toys. There were two entries where the Daily chronicle was read. There was no other variety of activities or participation engagement. Further, of the 6 weekends reviewed for the timeframe above, Resident 3 only received one-on-one engagement on 6/8/24 and 6/15/24. There was no documentation of additional weekend engagement for Resident 3. An annual assessment, titled Preferences for Customary Routine and Activities, dated 1/8/24 indicated, information was obtained from the staff as Resident 3 was unable to answer for herself. The assessment indicated, Resident's 3 preferred time to get out of bed was after breakfast. Every other item was coded, No response or non-responsive. A quarterly assessment, titled Preferences for Customary Routine and Activities, dated 4/12/24 indicated, Resident is 1:1 enjoys lotion applied to hands, calming music, childlike toy animals. Resident 3's comprehensive care plans were reviewed: She had a care plan dated 1/8/24 which indicated, Resident requires individualized activity programming due to having the inability to participate in daily programming. Previous/current interests include lotion applied to hands, listening to calming, soft music, stuffed animals. The only intervention listed for this plan of care was, one-to-one visits, Monday, Wednesday and Friday. She had a care plan dated 5/1/2013 which indicated, Female resident with diagnosis of MR [mental retardation]. Her mental/emotional age is that of a 5-year-old or less. She enjoys have her room decorated in a juvenile theme such as Hello Kitty and princess theme, as evidenced by her smile and laughter when she sees the decorations. Will be involved in activities of interest that promote socialization with others and sensory stimulation. Not eligible for OBRA services. This care plan included the following three interventions, all dated 5/1/2013: 1. Resident will be involved in sensory activities such as having her nails done, lotions and massage, music. 2. Resident will be encouraged to socialize i.e. make eye contact and allow staff to interact with her by holding her hand to promote psychosocial wellbeing. 3. Resident's room to be decorated with comforter, pillow cover, wall decor and accessories in Hello Kitty and princess theme. No additional goals or interventions had been added/revised to her care plan for cognitive abilities, preferences, routines and activity engagement. On 7/11/24 at 1:00 p.m., the Regional Social Enrichment Support Specialist provided a copy of current, but undated facility policy titled, Domains of Wellness & the Social Enrichment Program. The policy indicated, the wellness and enrichment of our residents is a large part of our mission to compassionately serve each resident with quality of care and excellence .for a resident who does not or cannot engage in a meaningful way in either group or independent activities, a One on One program of engagement is required .One on One programs should be individualized based on the resident's life story, preferences and historical activity pursuits .residents who are able should also be considered for other types of group activities such as sensory groups. This will allow some socialization in addition to their One on One engagement 3.1-33(a)

Based on observation, interview, and record review, the facility failed to ensure residents environment remained free of accident hazards when medications were not secured for 2 of 8 residents reviewed for secured medication (Resident E and 12). Findings include: 1. On 7/8/24 at 12:20 p.m., Resident E was observed to have her albuterol rescue inhaler in the dining room. The MCSS (Memory Care Support Specialist) indicated to the resident she needed the resident to give her the albuterol inhaler. The resident indicated she could not have it. The MCSS did not get the albuterol inhaler before Resident E went to her room. During a conversation, in her memory care (MC) room, on 7/8/24 at 12:28 p.m., Resident E indicated she still had her albuterol inhaler in her room. She showed the inhaler in her pocket. During an interview, on 7/8/24 at 12:32 p.m., Regional Support Services indicated she was getting agitated in the dining room, so they would re-approach her later. During an interview, in her MC room, on 7/10/24 at 9:24 a.m., Resident E indicated she had her albuterol inhaler, and it was observed in her right pocket. She indicated she had it yesterday too. She showed the inhaler had 66 puffs left in it. During an interview, on 7/10/24 at 11:29 a.m., the Interim Director of Nursing (DON) indicated she talked with the MC nurse this morning and she told the DON she got the albuterol inhaler back from the resident this morning. She indicated she was not aware of the resident had another albuterol inhaler in her pocket. She would go back to MC and try and get the second albuterol inhaler from Resident E. On 7/10/24 at 11:34 a.m., the DON indicated she got the second albuterol inhaler from the resident. On 7/10/24 at 11:45 a.m., Resident E's record was reviewed. She was admitted on [DATE] with severely impaired cognition. Her diagnoses included, but were not limited to, Alzheimer's disease with early onset (brain disorder with loss of memory and thinking skills), epilepsy (brain disorder of sensory disturbance, loss of consciousness), chronic obstructive pulmonary disease (COPD) with hypoxia (respiratory failure). Her physician order, dated 5/29/24, for albuterol sulfate inhaler indicated to provide every 4 hours as needed for shortness of breath. Her respiratory care plan, dated 5/16/24, indicated Resident E had the potential for impaired gas exchange related to COPD, chronic bronchitis, and respiratory failure. A nursing approach indicated to administer her medications as ordered. 2. On 7/8/24 at 11:22 a.m., a pill was observed on Resident 12's over the bed table. She indicated it was a potassium pill. She got it with her morning medications and did not want to take it then. She was saving it for lunch time when she would have more food on her stomach. On 7/9/24 at 11:47 a.m., Resident 12 indicated she had folic acid pills in a easy-to-open, unlabeled prescription bottle on her bedside table and an over-the-counter bottle of folate (folic acid) was observed in the bedside table drawer. The unlabeled prescription bottle had 4 whole pills and 3 half pills. On 7/10/24 at 9:03 a.m., Resident 12 was observed to have the folic acid pills in an unlabeled prescription bottle on her bedside table and a bottle of folate pills observed in her top drawer of her bedside table. On 7/10/24 at 12:08 p.m., Resident 12's record was reviewed. She was admitted on [DATE]. Her diagnoses included, but were not limited to, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), and bipolar disorder (psychiatric illness with both manic and depressive episodes). Her physician orders included, but were not limited to, potassium chloride 20 mEq (milliequivalent), dated 2/7/24, by mouth, once a day, between 7:00 a.m. to 11:00 a.m. Her order for folic acid 1 mg by mouth was added on 7/10/24. During an interview, on 7/10/24 at 12:08 p.m., Regional Director of Clinial Services (RDCS) indicated the folic acid (folate) would be added to the self-administration assessment. During an interview, on 7/11/24, the Interim Director of Nursing (IDON) indicated medications should not be in resident rooms unless they have a medication self-administration assessment. A current policy, titled, Self-Administration of Medications, dated 8/98, was provided by the RDCS, on 7/10/24 at 11:04 a.m. A review of the policy indicated, .It is the policy of this facility to respect the wishes of alert, competent resident to self-administer prescribed medications, as allowable under state regulations .A physician order will be obtained specifying the resident's ability to self-administer medications and , if necessary, listing which medications will be included in the self-administration plan .Storage of self-administered medications will apply with state federal regulations. All bedside medications will be maintained in a secured location in the resident's room 3.1-45(a)(1) 3.1-45(a)(2)

Based on observations and record review, the facility failed to ensure appropriate mediation storage was implemented when single-dose vials were labeled and dated, stored external medications from internal medications and dated inhalers once opened for 2 of 4 medications carts observed (Carts 100 hall and 300 hall). Findings include: 1. On 7/8/24 at 9:45 a.m., the 300-hall medication cart was observed. The following was observed inside the cart: a. Hydrophilic wound care dressing (a topical ointment) was observed in a drawer with oral inhalers. b. Lidocaine injectable solution was in the cart and did not have a label or date on the vial. c. Resident 208 had an albuterol HFA 90mcg (microgram) inhaler. It lacked a date to indicate when it was opened. She also had an incruse ellipta 62.5 inhaler. It lacked a date to indicate when it was opened. d. Resident 21 had a breziri aerosol inhaler. It lacked a date to indicate when it was opened. e. Resident 46 had an albuterol sul inhaler 90mcg. It lacked a date to indicate when it was opened. 2. On 7/8/24 at 10:10 a.m., the 100-hall medication cart was observed. The following was observed inside the cart. a. Resident 43 had diclofenac sodium gel in the medication cart with oral inhalers. b. Resident 44 had a Ventolin inhaler 90mcg inhaler in the cart. It lacked a date to indicate when it was opened. A policy titled, Storage and Expiration of Medications, Biologicals, Syringes and Needles was provided by the Regional Director of Clinical Services (RDCO) on 7/9/24 at 1:34 p.m. It indicated, . Facility should ensure that medications and biologicals have not been retained longer than recommended by the manufacturer or supplier guidelines or . returned to the pharmacy or supplier . Facility should ensure that external use medications and biologicals are stored separately from internal use medications and biologicals . 3.1-25(j) 3.1-25(m) 3.1-25(n)

Based on record review and interview, the facility failed to administer a pneumococcal vaccination to a resident who gave consent to receive the vaccination for 1 of 4 residents reviewed for vaccinations (Resident 35). Findings include: On 7/11/24 at 10:25 a.m., a record review was completed for Resident 35. She had the following diagnoses which included but were not limited to unspecified dementia, unspecified protein-calorie malnutrition, type 2 diabetes, and asthma. On 3/26/24, the resident's responsible party signed a consent for Resident 35 to receive a pneumococcal vaccination. It was not administered. On 7/11/24 at 11:25 a.m., the Regional Director of Clinical Services (RDCO) indicated the vaccination was not administered and she would get it scheduled today. A policy was provided by the RDCO on 7/10/24 at 2:02 p.m. It indicated, .On admission resident(s) will be screened for pneumococcal vaccination. If a resident meets criteria .will be offered the vaccination . 3.1-18(b)(5)

A. Based on observations, interviews and record review, the facility failed to ensure non-pressure wounds on a resident's toes were treated in a timely manner and failed to follow up on an arterial doppler causing a delay in treatment of the wounds which resulted in osteomyelitis, gangrene, and cellulitis for 1 of 3 reviewed for quality of care (Resident 45). B. Based on observation, interview, and record review, the facility failed to ensure residents had appropriate skin assessments and interventions in place to address non-pressure wounds for 2 of 3 residents reviewed for skin management (Residents 31 and 21). The immediate jeopardy began on 4/25/23 when Resident 45 was noted to have developed new wounds on his left and right toes. No treatments were ordered until 4/27/23. The wound doctor observed the wounds on 4/28/23 and diagnosed the resident with osteomyelitis. A bilateral doppler ultrasound was ordered on 4/28/23 and completed on 5/1/23. However, the facility failed to follow up in a timely manner to receive the results which were not on the resident's file until 5/24/23. The resident went to the podiatrist on 5/22/23 where she was able to probe to the bone on both first and fifth digits. The podiatrist sent the resident to the hospital. The hospital admitted the resident with osteomyelitis of the left hallux and left fifth digit, cellulitis of the left foot, exposed bone on left hallux, and gangrene of left fifth digit. The resident would need amputations of the toes. The Executive Director (ED), the Director of Nursing (DON), the Regional Support for Social Services (RSS), and Regional Director of Operations (RDO) were notified of the immediate jeopardy on 5/24/23 at 2:28 p.m. The immediate jeopardy was removed on 5/26/23, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A. On 5/23/23 at 10:00 a.m., Resident 45's medical record was reviewed. Resident 45 was transferred from another skilled nursing facility and admitted to Washington Healthcare on 3/3/23. He admitted with diagnoses which included, but were not limited to, a history of non-ST elevation myocardial infarction (heart attack), cerebral infarction (stroke), congestive heart failure, type II diabetes mellitus (a blood sugar disorder), and need for assistance with personal care. A Transition of Care (TOC) document, dated 3/3/23, from the previous nursing facility indicated he had admitted to their facility with a diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone. It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone). A nursing admission assessment, dated 3/3/23 at 3:21 p.m., indicated Resident 45 admitted with two areas of compromised skin integrity. One ulcer was noted on his left great toe which measured 1.5 centimeters (cm) long by (x) 1 cm wide. A second ulcer was noted on his left 5th toe which measured 1 cm long by 1 cm wide. An option to proceed with wound care observation, was marked, no. A nursing admission progress note, dated 3/3/23 at 3:39 p.m., indicated Resident 45 was noted to have a 1.5 cm x 1 cm dark scab to his left great toe and a 1 cm x 1 cm area to the lateral side of his 5th toe which was red in color. A baseline care plan, initiated 3/5/23, indicated Resident 45 was at risk for further skin break down due to, .osteomyelitis to L [left] foot and arterial ulcers to L toes A second baseline care plan, initiated, 3/5/23, indicated Resident 45 was at risk for pain, also related to arterial ulcers on his left foot. The record lacked documentation of interdisciplinary team (IDT) follow up related to the areas noted on admission. The record lacked documentation the physician was notified of osteomyelitis in his left foot and/or the areas on his toes noted upon admission. On 3/15/23 Resident 45 was initially seen by the Medical Director (MD). The evaluation indicated no issues with the resident's skin and lacked a review of his history of osteomyelitis and the two areas noted on his toes upon admission. A follow up was conducted by the MD on 3/27/23. The evaluation lacked a review of his history of osteomyelitis and the two areas noted on his toes upon admission. Resident 45's shower sheet/bathing records were reviewed and revealed he had only received bed baths, and no skin issues were noted until 4/25/23 when the aide noted, right foot and left foot had open areas. A nursing progress note, dated 4/25/23 at 2:26 p.m., indicated Resident 45 was noted to have redness and drainage to his left 5th toe and great toe. The MD was onsite and made aware. The Nurse and MD observed Resident 45's left foot. The MD gave no new orders at that time. A new Skin Event was opened on 4/25/23 at 2:47 p.m. which indicated, yellowish drainage on the left great and 5th toes and bright red. Measurements were not recorded. The MD was made aware and gave no new orders. The skin event indicated, Resident noted to have redness and drainage to the left 5th and great toe .MD on site and was made aware. MD and writer observed resident left foot. No new orders given at this time. During an interview on 5/24/23 at 10:21 a.m., LPN 52 indicated she was working on 4/25/23 when a CNA notified her, Resident 45 had open areas on his right and left foot which she found during a bed bath. LPN 52 immediately went to assess the areas and upon her observation she was very concerned. His toes were black and had a lot of drainage. The MD was in the facility at that time, and she asked him to come look. LPN 52 and the MD observed Resident 45's feet. When LPN 52 and the MD left his room, the MD told her it looked like he had osteomyelitis. He showed her a picture example on his phone and indicated the resident would probably lose his foot. The MD did not give LPN 52 any orders at that time. During an interview on 5/25/23 at 6:40 p.m., CNA 53 indicated she worked weekend option and had only worked with the resident once before but not on a shower day. So 4/25/23 was the first time giving him a bath. He was really pleasant and cooperative. While giving him a bed bath she did the top area first and kept his socks on to keep him warm. When she got to the bottom, it was horrible. It was not a situation where she felt comfortable finishing the bath, dressing the resident and changing the bed. She needed to get help right way! It startled me to the point, I thought his toes are falling off, this is scary! She could not identify which toe was the problem as it was his whole foot. It scared me to death. His whole foot was pale. The doctor was there that day, and he came down to look at it. He pressed on the resident's foot, the resident said he could not feel the pressure. The foot was white and did not turn pink with pressure. CNA 53 was surprised he was not sent to the hospital. She indicated she had been a CNA long enough to know that his foot did not get that way in just a couple of days. She indicated there was no way his toes and foot could have been missed if the socks were being taken off during bed bath and it was important to inspect residents' feet. During an interview on 5/24/23 at 10:11 a.m., Licensed Practical Nurse (LPN) 51 indicated she did not recall any issues with Resident 45's feet until the new areas were found in April. She had returned to work after a weekend and saw a new skin event had been initiated by another nurse. She went to Resident 45 to inspect the area and was alarmed at the condition of his left foot. She asked LPN 52, (the nurse who opened the event on 4/25/23) about the areas. LPN 52 told her, a CNA found the areas and let her know. When she assessed the area, she was also concerned and even observed the foot with the MD, but he did not give any orders at that time. LPN 51 indicated, since she was told the MD was already aware, she notified the DON who instructed her to open additional events, get measurements, call the MD, and ask orders. LPN 51 described his toes as, very icky. The 5th digit was macerated with eschar and had yellow slough and drainage. There was a new area to the top of his great toe that was flattened and black. The top of his right great toe had redness and warmth and appeared possibly infected. LPN 51 indicated, the condition of his feet was advanced, and the areas could not have developed overnight. Resident 45 always wore the non-skid socks and did not complain about pain. He was in a regular bed, and it was not until the area were found that the footboard of the bed was removed. LPN 51 indicated Resident 45 usually only got bed baths, and the CNAs should have been removing his socks to observe his feet. A nursing progress note dated 4/27/23 at 3:25 p.m., indicated, Resident 45 was in bed and received a full assessment. New orders were noted for areas to top of his 5th toe, bottom of 5th toe, top of great left toe, inside 1st big toe, and right great toe. The corresponding Skin Events were reviewed: On 4/27/23 at 2:54 p.m., a new area located on the left 5th to which measured 1.3 cm long by 3.4 cm wide. Yellow slough was present as well as redness/warmth (a sign of infection). On 4/27/23 at 3:01 p.m., a new area located on the left bottom of the 5th toe which measured 1.5 cm long by 1 cm long with redness and warmth present. Also noted to be back/brown/dark. On 4/27/23 at 3:08 p.m., the top of the left great toe measured 2.8 cm wide by 2.7 cm long. It was an open area with yellow drainage, redness, and warmth were present. Also noted to be black/brown/dark, (two days prior had been right red). On 4/27/23 at 3:15 p.m., a new area located on the left inner 5th toe which measured 5 cm long by 2.1 cm wide. Yellow slough, redness, and warmth were present. On 4/27/23 at 3:05 p.m., a new area located on the right great toe which measured 1.5 cm long by 1.5 cm wide. It was noted to be bright red with warmth present. Physician's orders, initiated on 4/27/23 (2 days after wounds were found) indicated to cleanse the areas with wound cleanser, apply Xeroform (a type of wound dressing/treatment) and cover, daily. A physician's order was initiated on 4/28/23 to obtain a bilateral doppler ultrasound, (a noninvasive test that can be used to estimate the blood flow through your blood vessels). A nursing IDT progress note, dated 4/28/23 at 2:14 p.m., indicated, the DON, the Minimum Data Set Coordinator (MDSC), Unit Manager (UM) and Wound MD were present. Wounds were described as arterial ulcer on the left great toe with 25% epithelial 35% slough 40% eschar, mild serosanguineous exudate, edges intact, necrotic tissue removed. The Left 5th toe had no drainage, edges intact, 70% eschar and 30% epithelial. Treatments were in put in place, antibiotics, podiatry referral, and arterial doppler. A nursing progress note, dated 4/28/23 at 2:44 p.m., indicated the Wound MD was in to evaluate Resident 45's left foot. A new order was received to start a Peripherally Inserted Central Catheter (PICC) and antibiotic for 6 weeks. A nursing progress note, dated 5/1/23 at 1:21 p.m., indicated a contracted mobile diagnostic and imaging company was noted at the facility to obtain an arterial doppler for Resident 45's left foot. Results were pending. A physician's order for intravenous (IV) meropenem (an antibiotic medication) was obtained on 4/29/23 with the indication for osteomyelitis in the left great toe. A referral was made for Resident 45 to be evaluated and treated by a podiatrist and a nursing progress note, dated 5/22/23 at 10:00 a.m., indicated the doctor from the podiatrist office phoned to inform the facility that Resident 45 was being transferred to the emergency room (ER) for further evaluation and treatment and possible admission for amputation. On 5/24/23 at 8:30 a.m., a copy of a SOAP (subjective/objective/assessment/plan) evaluation conducted by the Doctor of Podiatric Medicine (DPM) was provided. The evaluation indicated, .patient states that for the past 6 months he has had ulcers on his left foot . Ulcer #1: located on the left great toe is Wagner Grade 3 [deep ulcer with abscess or osteomyelitis) arterial. Wound is full thickness and measured 1.5 cm long by 1.2 cm wide and 0.3 cm deep with moderate serous drainage, undermining noted and was able to be probed to the bone. Ulcer #2: located on the left 5th toe is Wagner Grade 3 arterial, full thickness and measured 2 cm long by 1.5 cm wide but depth could not be measured. Ulcer #2 had heavy purulent drainage, tan in color with 25% eschar and tunneling noted. Ulcer #2 was also noted with Erythema and fluctuant tracking along the planter aspect of the arch in line with the 5th flexor tendon. When lanced, purulent material expressed from the fluctuant area in the arch Plan: discussed bone infection and the implications it has on healing and limb loss . I stressed the need to treat the problem aggressively. Recommended excision of the infected [NAME] with culture and biopsy of the area . I am very concern with the appearance of the left foot. As there is purulent drainage and he is already on IV antibiotics with a PICC line. He also had exposed bone to 1st and 5th toes of the left foot necessitating amputation of both. He has non-palpable pulses which will need vascular work up before any surgery can be completed. He will also need an MRI. Advised he be sent to the hospital A hospital ER evaluation, dated 5/22/23, indicated Resident 45 came to the Emergency Department (ED) from the podiatrist for a possible arterial occlusion and osteomyelitis of left foot. The podiatrist could not find a pulse in his left foot there was evidence of first and fifth digit dry gangrene. There was drainage out of the planter aspect of the left foot. A CTA (Computed Tomography Angiography- a type of medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of your body) indicated, .left superficial femoral artery multiple tandem high-grade stenoses, occlusions and minimal reconstruction of the popliteal artery and runoff vessels, the posterior tibial artery is opacified across the ankle on delayed phase imaging A hospital podiatrist consult indicated the DPM was able to get quite a bit of pus out of the foot at bedside from the digit and extending into the medial arch concerning for abscess. She was also able to probe to the bone on both right and fifth digits. The DPM was concerned about blood flow as pulses were not palpated to the left foot, fifth digit had dry gangrene to the planter lateral aspect of the digit. There was a small area in plantar medial arch of necrotic ulcer. The report indicated, .patient has exposed bone on left hallux and gangrene of left fifth digit so will need amputation of these digits but would prefer to optimize perfusion first to help with healing of surgery, per DPM there was concern of infection tracking down flexor tendon, so I did order an MRI to assess for extent of infection During an interview on 5/23/23 at 12:54 p.m., Resident 45's Power of Attorney (POA) indicated, she was unaware Resident 45 had been sent to the hospital or that he had new wounds on his feet. She was concerned about how it would affect his ability to recover, since he was a diabetic and had a history of wounds. He had been doing so well and was recovering from the stroke, she had even planned to make arrangements to have her POA revoked so that he could be independent again. During an interview on 5/23/23 at 2:00 p.m., the MD indicated he rounded at the facility on a weekly basis and was usually in the facility every Tuesday from 10:00 a.m.- 6:00 p.m. He would visit residents upon their admission and conduct comprehensive assessment and evaluation. This assessment would include a comprehensive skin assessment, but only of exposed skin. He indicated, I only look at skin I can see, just the exposed parts. I do not typically check unexposed skin unless the resident and/or staff indicated there was a need, if there is a treatment or bandage in place, I don't remove it. During an interview on 5/23/23 at 2:06 p.m., Certified Nursing Assistant (CNA) 50 indicated, Resident 45 was complaint with his care and treatments. He was pleasant and agreeable. He was interactive and enjoyed conversations. CNA 50 only worked with Resident 45 in the previous couple of weeks, so she was unable to visualize his foot before he left, but she remembered that there was quite a bit of redness to his whole left foot and the start of redness to his right foot. His feet were tender, so she tried to be careful. During an interview on 5/23/23 at 2:51 p.m., the DON indicated Resident 45 never had a doppler ultrasound as a resident at the facility. The above stated physician order and progress notes were reviewed with DON at this time, and she indicated she would double check. During a follow up interview on 5/23/23 at 2:51 p.m., the DON indicated when Resident 45 admitted to the facility, he did not have any open areas that she could recall. Several weeks later, his toes didn't look right and they had begun to change color, so the wound doctor was called in for an evaluation. The DON indicated it was her expectation that upon admission and identification of any skin integrity issues, the areas should be reported to the IDT team, so that the IDT team could review, evaluate and determine if the areas needed to be followed up with or not. During an interview on 5/24/23 at 9:16 a.m., the DON provided a copy of the doppler results and indicated she logged onto the website and found that the results were uploaded so she was able to obtain a copy. Until that time, the results had not been obtained by the facility. It was the DON's expectation for nursing staff to follow up on tests results in a timely manner. The results of the doppler, dated 5/2/23, were reviewed and revealed, .1. Left dorsal pedis artery not visualized may not exclude occlusion. 2. Segmental stenosis in the rest of bilateral lower extremity arteries especially in bilateral superficial femoral and the visualized infrapopliteal arteries. Further examination suggested which may include CT angiography among other workup During an interview on 5/24/23 at 10:03 a.m., the Minimum Data Set Coordinator (MDSC) indicated she had conducted the nursing admission assessment on Resident 45. When the MDSC inspected his feet, she noted the two areas on his toe. She indicated as a nurse she could not diagnosis because that was out of her scope of practice. She did not know what to classify the areas as and that was why she put a follow up progress note in with more details about the areas. Additionally, it was important to note skin integrity issues on the admission assessment so that IDT could follow up as needed. The MDSC indicated, the areas were not open or draining at that time, and she indicated they looked more like scabs. When skin areas were noted on the admission assessment, it should trigger the IDT team to review and determine if further follow up was warranted or not. She did not know why the IDT team did not review his feet after admission. On 5/24/23 at 2:50 p.m., a visit was attempted with Resident 45 at the hospital. He was out of the room at that time. His nurse, a Registered Nurse (RN) for the hospital indicated, he was undergoing a stress test as a part of pre-surgery preparations. She indicated his left foot was in very bad condition and amputation was a certainty. The doctors were concerned about the extent and spread of the infection, as it may have traveled up his leg through the tendon in his foot. If they were unable to restore good enough blood flow to the leg, he may require an amputation below the knee. On 5/25/23 at 11:16 a.m., Resident 45 was observed while in-patient at the hospital. He was reclined in bed. His left foot was wrapped. When asked what happened to his foot, Resident 45 indicated, it's F----- up! When asked what happened, he indicated, I don't know I guess I just have wounds, I think they are going to take my foot off. When asked if the nurses and aids were checking his feet while he was at the facility, he indicated, he thought they were, but when he got bed baths he could not remember if they took his socks off or not. During an interview on 5/25/23 at 11:20 a.m., Resident 45's hospital nurse indicated he was receiving IV heparin due to the occlusions as a blood thinner to try and prevent another stroke. He was also on IV meropenem for the osteomyelitis. She checked his most recent physician notes and indicated, he was going to be transferred to another hospital for more extensive testing and procedures. An MRI performed the day before was positive for osteomyelitis to his whole left foot. On 5/25/23 at 11:30 a.m., Resident 45's left foot was observed. His 5th digit was observed to be fully black from the base of the toe to the tip of his toe, dry and looked like a stone. The tip of his great toe was observed. It was swollen and bulged outward with an oval shaped wound. The wound bed was noted with scant yellow slough, the edges were rolled over and macerated. The top/right side of his great toe had a scabbed, irregular shaped area with reddish-brown dried crust. There was a small puncture wound on the bottom of his foot, in the middle of his arch. Purulent drainage was noted. During an interview on 5/25/23 at 12:40 p.m., the Wound Doctor (WMD) indicated he was asked to see Resident 45 for new areas on his foot. He saw Resident 45 on 4/28/23. By the time, the WMD saw his foot, there was already exposed bone, and he was certain it was infected with osteomyelitis. He was not the doctor who ordered the arterial doppler therefore did not follow up for the results. If he had ordered the test, he would except results and follow up within a couple of days. On a follow up visit on 5/19/23 the WMD indicated it appeared to have worsened and if there had not already been a podiatrist referral scheduled, he would have sent him out. At this time, the WMD provided copies of his wound notes for review. An initial wound evaluation, dated 4/28/23, indicated wounds present on the left 5th toe and great toe. They were classified as arterial ulcers with osteomyelitis of the left great toe and the resident had a history of osteomyelitis of the left great toe and had a history of stroke and heart attack. The peripheral pulse was palpable but weak, his feet were pale, and the left great toe was erythematous and warm. Wound #1 was classified as full thickness with exposed bone and etiology of arterial insufficiency, located on the left 5th toe. The wound measured 1.5 cm long by 3.2 cm wide and 0.1 cm deep with subcutaneous tissue exposed and a small amount of serosanguineous drainage. There was a large (67%-100%) amount of necrotic tissue within the wound bed including eschar. Wound #2 was also classified as a full thickness arterial wound with exposed bone. The wound measured 4.2 cm long by 3.7 cm wide and 0.6 cm deep. There was bone, muscle and subcutaneous tissue exposed. There was a small amount of serosanguineous drainage noted and there was a large amount of necrotic tissue within the wound bed including eschar and adherent slough. At that time, the WMD gave new orders to start IV antibiotic of meropenem for osteomyelitis of the right great toe and also gave a general note, .refer to outside podiatrist regarding possible need for amputation of left toe/s. A WMD note, dated 5/5/23, indicated healing was unlikely and to anticipate then need for surgical intervention per podiatry. A WMD note, dated 5/19/23, indicated the left great toe area was stable but slightly enlarged. Plan was to continue IV meropenem for osteomyelitis but there was a concern that the antibiotic may not reach target tissue in a sufficient concentration to be effective given arterial insufficiency. Await input from podiatry consultant on 5/22. I am concerned the distal left foot remains at risk and amputation may yet be indicated . During a follow up interview on 5/25/23 at 3:10 p.m., the MD indicated he only visited with the resident on 3/14 upon his admission. At that time, he indicated there were no issues with his feet or legs. The MD indicated he did not recall anything significant about the resident's foot or toes. When the nursing progress note from 4/25/23 was read to MD, he indicated he did not recall seeing the resident's foot. On 5/24/23 at 2:15 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Nursing Admission/Return Admission Policy and Procedure, revised 2/2019. The policy indicated, It is the policy of American Senior Communities to provide baseline and accurate documentation of the mental and physical condition of each resident admitted . Initial Nursing Assessment: Admission Observation . a thorough head to toe assessment (including skin) must be done at admission. Any altercations in skin integrity must be identified on nursing assessment. They physician must be notified for specific treatment orders . After completion of the admission nursing assessment a Baseline care plan will be initiated for all new admissions On 5/24/23 at 2:15 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Skin Management Program, revised 5/2022. The policy indicated, .Procedure for altercations in skin integrity- Pressure and non-pressure . altercations in skin integrity will be reported to the MD/NP . Treatment will be obtained from MD/NP. All altercations in skin integrity will be documented on the admission observation in the medical record on the admission observations . The wound nurse/designee will be notified of altercations in skin integrity . the wound nurse/designee will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day On 5/24/23 at 2:15 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Labs and Diagnostics, dated 11/2017. The policy indicated, It is the policy of American Senior Communities to provide or obtain laboratory and diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services On 6/1/23 at 2:39 p.m., Resident 45's family member indicated he had his leg surgically amputated above the knee and was recovering. The immediate jeopardy that began on 4/25/23, was removed on 5/26/23, when the facility provided education to all nursing staff for admission process, skin management, and follow up for labs and diagnostics. Further, a facility wide skin-sweep was conducted for all residents as well as an audit of ordered labs/diagnostics to ensure timely follow up. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. B1. On 5/26/23 at 11:18 a.m., Resident 31 was randomly selected for review during the IJ removal. At that time, he was observed seated in his wheelchair beside his bed in his room. He was agreeable and allowed Licensed Practical Nurse (LPN) 23 to remove his socks and shoes, so that an observation of his feet could be conducted. Upon removal of his socks, his bilateral (both right and left) feet, were observed to be discolored. They were ashy and dusky dark purple. The discoloration continued up both of his legs to just below his knees. His legs were very dry, flakey, and scaley with shedding skin. His legs were also deep purple in color. When asked about the discoloration, LPN 23 indicated his legs were not discolored, he only had dry skin. On 5/26/23 at 12:40 a.m., Resident 31's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, cellulitis (bacterial skin infection) and peripheral vascular disease (PVD- A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs and can cause the color of the legs and feet to change which can be a sign that not enough nutrients or oxygen are able to be supplied to the legs and feet by the blood). He had a comprehensive care plan, initiated 1/30/21 and revised 5/23/23, which indicated he was at risk for ineffective tissue perfusion related to PVD. The care plan lacked person-centered revision and/or interventions that identified the discoloration of his bilateral lower extremities (BLE). He had a comprehensive care plan, initiated 8/12/202 and revised 5/23/23, which indicated he was at risk for further skin breakdown due to concerns which included, but were not limited to, cellulitis, history of venous ulcers and limited sensory perception. The care plan lacked person-centered revision and/or interventions to identify the discoloration of his BLE. He had a comprehensive care plan, initiated 8/12/20 and revised 5/23/23, which indicated he was at risk for pain related to a left hip fracture, decreased ambulation, PVD and refusal to bear weight on his left lower extremity. The care plan lacked person-centered revision and/or interventions to identify the discoloration of his BLE. Resident 31's weekly skin assessments were reviewed. The assessments completed between 1/27/23 - 5/19/23 all lacked documentation, indication, and/or intervention to identify and/or address the discoloration of his legs. A weekly skin assessment dated [DATE], indicated, a podiatry referral was needed. The record lacked documentation of follow up to schedule the podiatrist visit. The record lacked documentation of identification of his chronic discoloration, therefore no additional monitoring or interventions were in place. On 5/26/23 at 12:11 p.m., the DON provided a copy of a skin-sweep tool for Resident 31. She indicated, as a part of the IJ removal process, a facility-wide skin-sweep had been conducted to ensure residents had not developed new skin integrity issues which had not already been identified, and to ensure previously identified areas had appropriate treatments in place. The DON indicated she had conducted the skin assessment on Resident 31, and there were no areas of concern that she recalled. On 5/26/23 at 12:18 p.m., Resident 31's BLE were observed with the DON and Regional Clinical Consultant (RCC) 24. Upon visualization, the DON indicated, the discoloration of Resident 31's BLE were chronic and had always been there because of his PVD. He did not have any new open areas. His legs were always discolored and appeared to be very dry and flakey. 37981 B2. On 5/22/23 at 10:48 a.m., Resident 21 was observed in his room. He had 3 circular wounds to his face: one on his forehead, one between his eyebrows, and one on the end of his nose. He pulled up the sleeves of his shirt to show multiple circular wounds on his bilateral (both) arms. No dressings were observed. On 5/24/23 at 12:37 p.m., Resident 21's wounds were observed. He continued to have the three circular wounds to his face and six circular wounds to his bilateral anterior arms. He raised his shirt and indicated he had wounds on his belly button. He raised his shirt, exposing his lower back exposing 4 wounds. He pulled up his pant legs, exposing his bilateral lower legs. There were numerous wounds, approximately 50 small wounds. He had no dressings on any of these wounds. On 5/24/23 at 12:39 p.m., Resident 21 indicated he received his shower the day before. At the end of the shower he indicated he was all bloody. On 5/23/23 at 2:08 p.m., Resident 21's record was reviewed. His diagnoses, included but were not limited to chronic obstructive pulmonary disease (COPD), diabetes mellitus (blood sugar disorder), depressive episodes, chronic pain, cellulitis (inflammation of subcutaneous tissue) of bilateral (both) lower limb and right upper limb, insomnia (sleepless), pruritis (itching), anxiety disorder, and cognitive impairme[TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure hot water temperatures were safe for 4 of 7 resident rooms reviewed for excessive hot water temperatures, and failed to ensure a resident who was at risk for falls with a history of repeated falls had appropriate fall interventions in place to prevent the potential for additional falls (Resident 2). Findings include: 1. During a tour with the Maintenance Supervisor, on 5/21/23 at 2:14 p.m., several resident rooms were checked for excessive hot water temperatures in resident bathrooms. a. room [ROOM NUMBER] water temperature was 125.3 degrees Fahrenheit (F). b. room [ROOM NUMBER] water temperature was 133.1 degrees F. c. room [ROOM NUMBER] water temperature was 128.4 degrees F. d. room [ROOM NUMBER] water temperature was 131 degrees F. On 5/21/23 at 2:28 p.m., the Maintenance Supervisor indicated he knew the facility needed the mixing valves rebuilt. At least he was hoping to get the mixing valves rebuilt. They have been acting up for the last few months. If he turned the mixing valve clockwise it should cool down the resident water temperatures. He indicated he adjusted the mixing valve a little bit and for the most part that worked. On 5/21/23 at 2:30 p.m., Resident 32 indicated the water in his bathroom was way too hot. On 5/21/23 at 2:32 p.m., the water monitoring maintenance logs were reviewed with water temperatures above the normal parameters on the following dates: a. On 2/17/23, room [ROOM NUMBER]'s hot water temperature was 123.6 degrees F. No water adjustments were indicated. b. On 2/24/23, room [ROOM NUMBER]'s hot water temperature was 121.2 degrees F. No water adjustments were indicated. c. On 3/3/23, room [ROOM NUMBER]'s hot water temperature was 123.2 degrees F. No water adjustments were indicated. d. On 3/7/23, room [ROOM NUMBER]'s hot water temperature was 128 degrees F, room [ROOM NUMBER]'s hot water temperature was 126 degrees F, and room [ROOM NUMBER]'s hot water temperature was 122 degrees F. No water adjustments were indicated. e. On 3/14/23, room [ROOM NUMBER]'s hot water temperature was 130.5 degrees F and room [ROOM NUMBER]'s hot water temperature was 132.8 degrees F. No water adjustments were indicated. f. On 3/24/23, room [ROOM NUMBER]'s hot water temperature was 121.4 degrees F, room [ROOM NUMBER]'s hot water temperature was 126.6 degrees F, and room [ROOM NUMBER]'s hot water temperature was 121.5 degrees F. Water adjustments were indicated. g. On 3/29/23, room [ROOM NUMBER]'s hot water temperature was 121.4 degrees F. No water adjustments were indicated. h. On 4/4/23, room [ROOM NUMBER]'s hot water temperature was 120.2 degrees F. No water adjustments were indicated. i. On 5/2/23, room [ROOM NUMBER]'s hot water temperature was 123.6 degrees F, room [ROOM NUMBER]'s hot water temperature was 127.7 degrees F, room [ROOM NUMBER]'s hot water temperature was 125.9 degrees F, room [ROOM NUMBER]'s hot water temperature was 121.8 degrees F, room [ROOM NUMBER]'s hot water temperature was 122.9 degrees F, room [ROOM NUMBER]'s hot water temperature was 123.6 degrees F, and room [ROOM NUMBER]'s hot water temperature was 125.2 degrees F. Water adjustments were indicated. j. On 5/18/23, room [ROOM NUMBER]'s hot water temperature was 122.8 degrees F, room [ROOM NUMBER]'s hot water temperature was 124.6 degrees F, room [ROOM NUMBER]'s hot water temperature was 125.4 degrees F, room [ROOM NUMBER]'s hot water temperature was 125.1 degrees F, and room [ROOM NUMBER]'s hot water temperature was 120.2 degrees F. Water adjustments were indicated. On 5/21/23 at 2:51 p.m., the Executive Director (ED) indicated the Maintenance Supervisor would adjust the mixing valves and recheck the resident hot water temperatures again. On 5/21/23 at 2:53 p.m., the Mechanical room [ROOM NUMBER] was observed. The Maintenance Supervisor indicated the boiler temperature was set at 189 degrees Fahrenheit (F). The water from the boiler went directly to the hot water heaters. They had no temperature gauges. From the hot water heaters, the water went to the mixing valve, then the kitchen and the rest of the building. The mixing valve was set at 133 degrees F. He indicated he would turn the mixing valve clockwise to turn the hot water temperature down. On 5/21/23 at 2:58 p.m., the Mechanical room [ROOM NUMBER] was observed. The Maintenance Supervisor indicated it had no boiler. The water came in through the recirculation lines. There were 2 mixing valves, one temperature gauge read 127 degrees F, and the second read 128 degrees F. The water went directly to the residents' rooms from there. If the hot water temperatures were too hot he would adjust the mixing valves and wait for the water to recirculate, but he did not log the temperature rechecks for the resident rooms. The facility had many EDs recently, and it made it difficult to get the company to pay for expensive mixing valves. He did not have enough in his budget to buy them himself. On 5/21/23 at 3:06 p.m., the shower rooms were checked. a. The 300 Hall shower area sink temperature was 133 degrees F, and the shower was 133.5 degrees F. b. The 100 Hall shower area sink temperature was 126.7 degrees F, and the shower was 121 degrees F. On 5/22/23 at 9:37 a.m., the ED indicated a plumbing services company was in the building checking on the mixing valves. On 5/22/23 at 9:40 a.m., the Maintenance Supervisor indicated the plumbing services company replaced one mixing valve on 5/21/23 in the boiler room. On 5/22/23 at 9:45 a.m., the Maintenance Supervisor provided documentation of checked and rechecked hot water temperatures from 5/21/23 evening and the morning of 5/22/23. Two resident rooms' 321 and 322 were too hot. The Maintenance Supervisor adjusted the mixing valve. The plumbing services company arrived at 6:40 p.m. Left to get a mixing valve at 9:30 p.m. and finished the repair at 10:25 p.m. Eight resident rooms were checked after the mixing valve was replaced and all were within normal parameters. On 5/22/23, starting at 6:00 a.m., 12 resident rooms were checked and were all within normal parameters. On 5/22/23 at 2:45 p.m., four resident rooms were rechecked with the Maintenance Supervisor. room [ROOM NUMBER]'s water temperature was still above the acceptable level at 123.2 degrees F. The Maintenance Supervisor indicated he did not understand why it was too high and he would adjust the mixing valve again. On 5/23/23 at 10:45 a.m., the ED indicated the plumbing services company was at the facility to determine long term fixes for the old building. On 5/25/23 at 12:19 p. m., the ED provided a copy of the Maintenance Supervisor job description. A review of the document indicated, .The Maintenance Supervisor is responsible for providing maintenance services to create a safe, sanitary, and homelike environment for residents, staff, and the public .Essential Position Functions .Tests facility hot water system on regular basis to evaluate water temperatures in essential location of facility A current policy titled, Water Borne Pathogen Prevention Policy, dated April 2018, was provided by the Maintenance Supervisor, on 5/26/23 at 1:34 p.m. A review of the policy indicated the, .The facility utilizes its preventive program and Water Management team to monitor the building water system. The facility has an on-call maintenance program so that when issues are identified staff is able to contact a member of the water management team 38768 2. On 5/23/23 at 9:15 a.m., Resident 2's medical record was reviewed. She was a long-term care resident with diagnoses which included, but were not limited to, weakness, repeated falls, abnormal posture and need for continuous supervision. As of the review date of 5/23/23, Resident 2 had current physician's order for anti-roll backs and an auto-lock brake system to be installed on her wheelchair. A nursing progress note, dated 5/21/23 at 5:48 a.m., indicated Resident 2 was observed by staff as she self-transferred onto her wheelchair. Wheelchair flipped and resident sat on floor. The resident stated she did not know how the wheelchair flipped but she was ok. An interdisciplinary team (IDT) progress note, dated, 5/22/23 at 10:57 a.m., reviewed Resident 2's fall. A description of the fall: Resident was seen transferring self into wheelchair when the wheelchair tipped causing resident to sit on the floor in front of wheelchair. Resident immediately assessed with no injuries noted, resident did not hit her head. Resident has been approved by therapy to transfer self. Determined root cause of fall: Appears that wheelchair was not locked, and wheelchair was not stable for resident to transfer into wheelchair. Intervention put in place to address root cause of fall: Auto-lock brakes to be placed on wheelchair. Resident 2 had a comprehensive care plan, initiated 5/19/16 and revised 5/22/23. The care plan indicated Resident 2 was at risk for falls related to her age, her history of falls, generalized weakness and that was unaware of her physical limitation at times. Interventions for the plan of care included, but were not limited to anti-roll backs, auto-lock brakes, and dycem to wheelchair. On 5/22/23 at 11:13 a.m., Resident 2 was initially observed. She was seated in a regular wheelchair, in the main dining room. The wheelchair did not have anti-roll backs and/or an auto lock brake system in place. There was no pressure reducing cushion, and no dycem (a thin rubber layer to help prevent cushion from sliding) in place. On 5/22/23 at 2:16 p.m., Resident 2 was observed in the same wheelchair, without anti-roll back or auto-locks in place. On 5/23/23 at 9:06 a.m., Resident 2 was observed as she independently maneuvered in the same wheelchair. She was in the front main entrance lobby at that time. There were no anti-roll backs or an auto-lock brake system in place. On 5/23/23 10:10 a.m., Resident 2 remained in the same wheelchair. She was in the main dining room area. She used her foot to push herself slowly back and forth, which created a rocking motion in her wheelchair. There were no anti-roll backs, or an auto-lock brake system in place. On 5/2423 at 2:00 p.m., Resident 2 was observed with the Director of Nursing (DON). The DON looked at the back of the wheelchair and underneath the seat. She indicated there were no anti-roll backs or an auto-lock brake system installed on the wheelchair. On 5/24/23 as 2:06 p.m., The Regional Clinical Consultant (RCC) 20, the DON, and Executive Director (ED) indicated Resident 2 was not in the proper wheelchair. They found Resident 2's wheelchair which was sitting outside of a room in the hallway. Upon observation, her wheelchair did have anti-roll backs and an auto-lock brake system installed. The DON indicated she did not know why Resident 2 was not in the appropriate wheelchair. On 5/24/23 at 2:15 p.m., the DON provided a copy of current facility policy titled, Fall management Policy, revised 8/2022. The policy indicated, It is the policy of American Senior Communities to ensure residents residing within the facility receive adequate supervision and or assistance to prevent injury related to falls . the residents specific care requirements will be communicated to the assigned caregiver utilizing resident profile or CNA assignment sheet 3.1-45(a)

Based on observation, interview, and record review, the facility failed to ensure supplies and foods were stored appropriately, food was dated and labeled, the kitchen was sufficiently cleaned, sinks were not leaking in kitchen area, and the dumpster lids were closed for 1 of 1 days of kitchen observation. Findings include: On 5/21/23 at 10:14 a.m., Cook 12 provided a tour of the kitchen. In the dry storage area: a. Two boxes of plastic utensils were open to the air with the inner plastic bag around the outside of the boxes. b. A bag of pork flavored gravy mix was open to the air. c. A bag of Quaker grits, with no open date, was rolled down and not sealed. The reach-in refrigerator: a. A large plastic container of gravy had no label or date. b. A large container of American cheese was not dated. c. Five single serving containers of pureed bread were not dated. Cook 12 indicated he did not know when they were prepared. d. A container of ham salad was dated to expire on 4/28/23. e. A container of romaine lettuce was open to the air. f. A foil wrapped cheddar cheese was opened, the edges of the cheese had dried out. There was no date. The bottom front of the reach-in refrigerator was observed to be spilled upon and had unidentifiable food debris on it. The unused grill portion of the stove top was observed to be unclean. The steam catch pan under the steamer was 1/2 full of dirty, lime water with white residue at the bottom. Cook 12 indicated the kitchen should have been cleaned every evening. The walk-in freezer had a large sausage on the freezer floor. The breadsticks were open with no open date on them. The walk-in refrigerator had hot dogs and sausage in a large container with no dates. A container of shredded carrots was open with no date. A large container the shredded lettuce did not have a date on it. Under the stainless steel table by the dishwasher, drywall, grout, and broken tiles were observed on the floor. The three-compartment sink was leaking and there was standing water on the kitchen floor near the dishwasher. Cook 12 indicated he notified the Maintenance Supervisor three days ago. A handwashing sink near the dishwasher was loose from the wall. A wooden board was observed on the floor. Cook 12 indicated the wooden board was used to hold the handwashing sink against the wall. He turned on the water and indicated the sink leaked water onto the floor because the drain had separated from the wall. The handwashing sink was observed to be very dirty. Cook 12 indicated the MM was well aware of the handwashing sink issues. A full trash bag was observed still open, outside at the back door. Cook 12 picked it up and took it to the dumpster. The recycle dumpster was observed with the lid open. The trash dumpster was observed with the lid open and a lot of trash on the ground. The gate to the dumpster area was not closed. Cook 12 indicated there was so much trash on the ground because the raccoon's get in there and drag out the trash On 5/25/23 at 9:37 a.m., Dietary Aide (DA) 56 was observed to wash his hands, he dried them with a paper towel, then turned the faucet off with his bare hand. He was observed making green bean casserole soup. On 5/21/23 at 1:08 p.m.,. the Executive Director (ED) indicated if the Maintenance Supervisor was qualified to do repairs in the building, then he would do it. On 5/21/23 at 1:56 p.m., the Dietary Manager (DM) indicated the plastic utensils should have been covered in box. She indicated the facility really did not use plastic utensils. All foods should have been dated, labeled, and sealed. The kitchen should have been cleaned. The dishwasher area should have been in good repair regarding the drywall, grout, and tile. A current policy titled, Food Storage, dated 5/23, was provided by the Executive Director (ED), on 5/21/23 at 3:20 p.m. A review of the policy indicated, .Leftover prepared foods and processed meats such as lunch meat, are to be stored in covered containers or wrapped securely. The food must clearly be labeled with the name of the product, the date it was prepared, and marked to indicate the date by which the food shall be consumed or discarded .Refrigerated, ready-to-eat, potentially hazardous food purchased from approved vendors shall be clearly marked with the date the original container is opened and the date by which the food shall be consumed or discarded .All foods shall be covered or wrapped tightly, labeled, and dated A current policy titled, Food Safety, dated 10/22, was provided by the ED, on 5/22/23 at 1:58 p.m. A review of the policy indicated, .The Culinary Manager is responsible for providing safe food to all residents A current policy titled, Cleaning Schedules, dated 5/23, was provided by the ED, on 5/22/23 at 2:27 p.m. A review of the policy indicated, .The culinary staff will maintain the sanitation of the culinary department A current policy titled, Food Storage, dated 5/23, was provided by the ED, on 5/26/23 at 2:37 p.m. A review of the policy indicated, .Culinary employees with facial hair must also wear a beard restraint A current policy titled, Water, Plumbing and Waste, dated 5/23, was provided by the ED, on 5/22/23 at 1:58 p.m. A review of the policy indicated, .Refuse, recyclables, and returnables shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure a medication cart remained locked while unauthorized residents and visitors passed it for 1 of 1 random observation, and further failed to ensure a resident did not have medications in his room without a self-administration assessment for 1 of 1 resident reviewed for self-administration assessments (Resident 17). Findings include: 1. On 5/24/23 at 9:42 a.m., Licensed Practical Nurse (LPN) 52 was observed removing a 3 milliliter (mL) albuterol nebulizer treatment medication for Resident 17. She did not lock the medication cart when she walked away and off the unit. There was no nurse in line of sight of the cart, the nurse's station was empty. On 5/24/23 at 9:42 a.m., Mattress Company Employee 71 was at the facility to change out several mattresses. He was observed standing near the unlocked and unattended medication cart. On 5/24/23 at 9:44 a.m., Resident 17 was observed outside his room in a wheelchair, waiting for his nebulizer treatment and new mattress. On 5/24/23 at 9:45 a.m., the DON acquired Resident 17's oxygen saturation (O2 sat) near the unlocked medication cart. On 5/24/23 at 9:49 a.m., LPN 52 returned with PPE (personal protective equipment), took Resident 17 into his room for an albuterol nebulizer treatment. The medication cart was still observed to be unlocked and unattended. Resident 4 was observed in her wheelchair in the hall. LPN 4 walked past the unlocked medication cart. On 5/24/23 at 9:52 a.m., Mattress Company Employee 71 was observed going in the out of resident rooms facilitating the mattress changes. He remained on the hallway with the unlocked and unattended medication cart. On 5/24/23 at 9:53 a.m., Resident 4 was observed to stop in front of the unlocked and unattended medication cart for several seconds, then she continued self-propelling herself down the hallway. On 5/24/23 at 9:55 a.m., Mattress Company Employee 71 passed in front of unlocked and unattended medication cart again. On 5/24/23 at 10:01 a.m., the DON passed in front of the unlocked and unattended medication cart. On 5/24/23 at 10:02 a.m., the DON passed in front of the unlocked and unattended medication cart going the other way. On 5/24/23 at 10:03 a.m., Clinical Dietitian Assistant 72 passed by the unlocked and unattended medication cart. On 5/24/23 at 10:04 a.m., LPN 52 came out of Resident 17's room and locked the medication cart. She indicated the medication cart should have been locked when she was away. 2. On 5/24/23 at 11:02 a.m., Allergy Relief (diphenhydramine - antihistamine) 25 mg bottle was found on the floor, in front of his bedside table, of Resident 17's room. On 5/24/23 at 11:20 a.m., showed LPN 5 the bottle of Allergy Relief pills on the floor in front of his bedside table. She indicated they should not have been in his room. She asked Resident 17 why they were in his room. He indicated he forgot he had them. A current policy titled, Storage and Expiration Dating of Medications, Biologicals, was provide by the Executive Director (ED), on 5/25/23 at 12:19 p.m. A review of the policy indicated, .Facility should ensure that all medication and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors 3.1-25(i)

Based on interview and record review, the facility failed to designate a qualified person to fulfill the role of the Infection Preventionist (IP) at least part-time. This deficient practice had the potential to effect 54 of 54 residents who resided at the facility. Findings include: During an interview with the and DNS on 5/26/23 at 11:46 a.m., she indicated she had earned a certificate for IP in July of 2019. She indicated she was performing the role of the IP nurse for the facility. The facility assessment was reviewed on 5/26/23 at 12:00 p.m. It indicated there was a position of an IP nurse and next to the position it indicated, Based on characteristics of facility, does this role need to be dedicated solely to the IPCP (Infection Prevention Control Program)? During an interview with the Executive Director (ED) and Director of Nursing (DON) on 5/26/23 at 2:12 p.m., they indicated they were not aware they needed to have a nurse for the role on a part-time basis. A policy titled COVID-19 Policy, dated 9/27/22, was provided by the ED on 5/22/23 at 11:06 a.m., indicated, .The facility will follow CMS and IDOH guidelines.

Based on observation, interview and record review, the facility failed to ensure person-centered comprehensive care plans were reviewed and revised in a timely manner to accurately reflect the resident's conditions for 3 of 5 residents reviewed for care plans (Resident 18, 21, and 52). Findings include: 1. On 5/22/23 at 10:50 a.m., Resident 52 was observed lying in bed with the sheet off of his lower legs. Resident 52 did not have any wound dressings on his feet. Resident 52 indicated he did not have any wounds on his feet. A comprehensive record review was completed on 5/24/23 at 12:30 p.m. He had the following diagnoses, but not limited to acute infarction of the spinal cord, muscle weakness, anxiety, orthostatic hypotension, neurogenic bowel, neuropathic bladder, and paraplegia. The record lacked documentation of any physician's orders for treatments and current wound measurements to Resident 52's feet. Resident 52 had a care plan dated 3/13/23 that indicated he admitted to the facility with a pressure injury to his left heel. He was at risk for impaired healing due to paraplegia state, mechanical lift, neurogenic bladder and bowel, hypotension, alcohol abuse, need for assistance with personal care, anxiety, and tethering equipment against skin. The goal, dated 6/13/23, indicated the wound would be free of signs and symptoms of infection. Interventions included to notify the physician of worsening or no change in wound or for signs and symptoms of infection and to assess wound weekly including documenting measurements and the description of the wound. 2. During an observation on 5/22/23 at 9:30 a.m., Resident 18 was observed wheeling himself in a wheelchair near the front entrance of the facility. He was wearing headphones and indicated he was having a great day. A comprehensive record review was completed on 5/25/23 at 2:30 p.m. Resident 18 had the following diagnoses but not limited to type 2 diabetes mellitus, end stage renal disease, weakness, seizures, neuropathy, absence of left leg below knee, benign prostatic hypertrophy, anemia, essential hypertension, chronic obstructive pulmonary disease, depression, and myocardial infarction. Resident 18 had a care plan, dated 1/26/23, that indicated he was at risk for elopement per the elopement risk assessment. The goal, dated 7/19/23, indicated resident was to remain safely in the facility through the next review. An intervention, dated 1/26/23, indicated to redirect resident to activities of interest such as going to the dining area for activities. During an interview with the Executive Director on 5/26/23 at 11:26 a.m., she indicated Resident 18 was not at risk for elopement. She indicated he wheeled himself around with his headphones on listening to music. 37981 3. On 5/23/23 at 2:08 p.m., Resident 21's record was reviewed. His diagnoses, included but were not limited to chronic obstructive pulmonary disease (COPD), diabetes mellitus (blood sugar disorder), depressive episodes, chronic pain, cellulitis (inflammation of subcutaneous tissue) of bilateral (both) lower limb and right upper limb, insomnia (sleepless), pruritis (itching), anxiety disorder, and cognitive impairment. A self-administration care plan, revised 4/13/23, indicated Resident 21 chose to self-administer topical medication. The goal was to safely self-administer medications. The nursing approaches were to complete the ASC (American Senior Communities) Medication Self Administration Request/Evaluation quarterly as needed, keep the medications out of reach of other residents, notify the MD of any problems, and provide education to resident on proper use of medication. A nursing progress note written by the Director of Nursing (DON), dated 5/4/23 at 8:11 a.m., indicated the pharmacy notified the facility of a non-covered medication: Temovate (clobetasol). The physician was updated and the was order was discontinued due to non-compliance. The resident was notified. A physician order, discontinued on 5/4/23, indicated to apply Temovate (clobetasol) (a highly potent steroid that helps reduce inflammation in the body to treat inflammation and itching caused by skin conditions) 0.05 % ointment topically every shift to the bilateral lower extremities. The April and May Medication Administration Records (MARs) were reviewed. Resident 21 had continuous use of Temovate (clobetasol) until it was discontinued on 5/4/23. On 5/26/23 at 10:56 a.m., the Clinical Regional Consultant 24 indicated Resident 21 did not have a self-administration assessment for medications. A current policy, titled, IDT (Interdisciplinary Team) Comprehensive Care Plan Policy, dated 10/2019, was provided by the Executive Director (ED), on 5/24/23 at 12:22 p.m. A review of the policy indicated, .Each resident will have a comprehensive person-centered care plan developed based on comprehensive assessment. The care plan will include measurable goals and resident specific interventions based on resident need .Care plan problems, goals, and interventions will be updated based on changes in resident assessment/condition, resident preferences or family input 3.1-35(a) 3.1-35(b)(1) 3.1-35(c)(1) 3.1-35(c)(2)

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate nail care for 3 of 3 residents reviewed for nail care (Residents 20, 211, and 212). Findings include: 1. On 5/21/23 at 11:30 a.m., 5/22/23 at 9:40 a.m., and 5/23/23 at 11:20 a.m., Resident 211 was observed lying in bed. His fingernails were long with a dark brown substance under his nails. During an observation on 5/24/23 at 10:59 a.m., Resident 211 was sitting up in the dining room with a hospital gown on. He indicated he wanted to keep his facial hair and wound like a haircut. His nails were trimmed and clean. A record review was completed on 5/25/23 at 11:09 a.m. Resident 211 had the following diagnoses, but not limited to sepsis, protein-calorie malnutrition, benign prostatic hypertrophy, obstructive uropathy, weakness, cognitive communication deficit, malignant neoplasm of the bronchus of the lung, malignant neoplasm of the brain, and pulmonary embolism. His care plan, dated 5/15/23, indicated he was a new admission to the facility, and he required implementation of services to promote physical, emotional, and psychosocial well-being including assistance with activities of daily living related to muscle weakness. An intervention indicated to assist with transfers, ambulation, bed mobility, toileting and/or incontinent care, eating, drinking, and bathing/hygiene including oral/dental care. 2. During an observation on 5/21/23 at 11:35 a.m., Resident 212 was lying in bed with his feet elevated off the bed. His television was turned off and the room was dark. His nails were long and had a dark substance under the nails. During an observation of 5/22/23 at 9:42 a.m., Resident 212 was observed lying in bed. His nails were long with a dark brown substance under the nails. During an observation on 5/23/23 at 11:15 a.m., Resident 212 was observed lying in bed. His nails were long with a dark brown substance under them. During an observation on 5/24/23 at 10: 54 a.m., Resident 212 was observed lying in bed. His nails were trimmed and clean. A record review was completed on 5/25/23 at 11:20 a.m. Resident 212 had the following diagnoses, but not limited to sepsis, type 2 diabetes mellitus, essential hypertension, protein-calorie malnutrition, hyperlipidemia, obstructive uropathy, pressure ulcer right heel, weakness and depression. His care plan, dated 5/11/23, indicated he was a new admission to the facility, and he required implementation of services to promote physical, emotional, and psychosocial well-being including assistance with activities of daily living related to muscle weakness. An intervention indicated to assist with transfers, ambulation, bed mobility, toileting and/or incontinent care, eating, drinking, and bathing/hygiene, including oral/dental care. During an interview with the Executive Director (ED) on 5/23/23 at 2:10 p.m., she indicated nursing staff were to perform nail care for the residents. 37981 3. On 5/21/23 at 11:29 a.m., Resident 20 was observed with long, uncut fingernails with brown debris under them. He indicated he was on hospice and was showered about a week ago. On 5/22/23 at 10:32 a.m., Resident 20 was observed with long, uncut fingernails with brown debris under them. On 5/25/23 at 9:31 a.m., Resident was observed with long, uncut fingernails with brownish debris under them. On 5/23/23 at 10:26 a.m., Resident 20's record was reviewed. His diagnoses included, but were not limited to, Metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), end-stage renal disease (kidney failure), diabetes mellitus (blood sugar disorder) with diabetic neuropathy (type of nerve damage that can occur with diabetes), acute (sudden onset) respiratory failure with hypoxia (low oxygen levels in the blood). On 5/23/23 at 10:29 a.m., Resident 20's care plan goals were reviewed. One indicated the resident was to have their ADL (activities of daily living) needs met, another goal was for the resident to achieve the highest desired practicable level of physical, emotional, and psychosocial well-being. A policy was not provided for ADL care, however a Skills Competency was provided. It was dated 2/2010. A review of the Skills Competency indicated to, .assist resident with toileting or perineal care as needed .assist resident to wash face, hands, and under arms assist resident with oral hygiene .have resident, if needed .assist resident with dressing, including applying make-up and /or jewelry as requested .comb and style resident's hair per preference 3.1-38(a)(2)(A)

Based on interview and record review, the facility failed to provide services to prevent the development of a pressure sore for 1 of 4 residents reviewed for pressure sores. This deficient practice resulted in Resident B acquiring a Stage III (full thickness skin loss) pressure area. Finding includes: Resident B's closed clinical record was reviewed on 5/30/17 at 10:59 a.m. An admitted was noted of 4/27/17. [DIAGNOSES REDACTED]. The admission nursing assessment, dated 4/27/17, indicated the resident had no skin impairment. A Braden Scale for Predicting Pressure Sore Risk, completed on 5/3/17, coded the resident with a score of 15, which put the level at AT RISK. The assessment identified areas of risk due to sensory perception, moisture, activity, mobility, and nutrition. An Event Report for a New Skin Event, dated 5/7/17, included a new wound/area originally noted on 5/7/17, not present on admission. 6.5 cm (centimeters) by 10.2 cm by 0.25 cm. A narrative progress note on the Event Report, included 5/7/17 at 7:44 p.m. CNA (Certified Nurse Aide) came to writer because he noticed serosanguinous drainage on the resident's bed, prompting the CNA to remove sock. Upon sock removal, left heel skin came off. Area measured at 6.5 cm by 10.2 cm by less than 0.25 cm. Small amount of serous drainage which stopped in short period. Exposed area is reddish pink in color. Cleansed area, patted dry, applied Purachol, (first aid ointment) covered with [MEDICATION NAME] (dressing) and wrapped with Kerlix (gauze wrap). Applied Heelz Up device. Resident tolerating Heelz Up and tx (treatment) well. Some discomfort during tx but resolved upon completion. Family and MD (medical doctor) notified. A wound report completed by the Director of Nursing Services (DNS), dated 5/7/17, indicated, .Wound Type: Pressure Ulcer Left heel not present on admission .length 6.5 cm by 10.2 cm width, by 0.2 cm depth .Light exudate,. Exudate serosanguinous pale red to pink, thin and watery, no odor .Stage III (full thickness loss) .90 percent of wound covered by granulation tissue .Wound edges/margins: Edges not attached to base; well defined wound edges An Admission Minimum Data Set (MDS) assessment, dated 5/4/17, coded the resident with no cognitive impairment. Required extensive assistance of two for bed mobility and transfers. Required total assistance of one for locomotion, was non-ambulatory. The assessment coded the resident as being in physical and occupational therapies. Physical therapy plan of care notes, provided by the Physical therapist on 5/30/17 at 1:00 p.m., addressed assessment of the resident's functional deficits for mobility, toileting, assessed the resident as substantial/maximal assistance; dependent, Helper does ALL of the effort. Resident does none of the effort to complete the activity .or None attempted due to medical condition or safety concerns A plan of care with problem start date of 5/10/17, addressed the problem of Resident is at risk for skin breakdown or further skin breakdown due to: limited mobility, obesity, incontinence, weakness. Approaches included assessments and documentation of skin condition; encourage to eat at least 75 percent; house barrier cream as needed; incontinent care as needed; pressure reducing/redistribution mattress and wheelchair cushion; preventative treatments as ordered; supplements as ordered; and turn and reposition at least every two hours. Another plan of care, dated 5/10/17 addressed the problem of impaired skin integrity: left heel wound. Approaches were the same plus assessments for pain, and notify the physician of unrelieved/worsening pain; weekly wound measurements and description; labs as ordered; observe for signs of infection; and wound healing vitamins as ordered. No approaches were noted about pressure prevention against the footboard of the bed. Licensed Practical Nurse (LPN) #1 was interviewed on 5/30/17 at 11:30 a.m. She indicated the resident weighed over 400 pounds, had diabetes, [MEDICAL CONDITION], and did not follow dietary restrictions for the diabetes. She indicated he laid in bed a lot. The Director of Nursing Services (DNS) was interviewed on 5/31/17 at 10:20 a.m. He indicated the resident liked to sit up in bed and then slide down until in contact with the footboard. Eventually the footboard was removed and the resident was ok with it. The Assistant Director of Nursing Services (ADNS) was interviewed on 5/31/17 at 10:20 a.m. She indicated therapy had been contacted due to the resident liked to put feet/heels against the footboard or on the top. A policy titled Skin Management Program, with most recent revision date of 9/2016, provided by the ADNS on 5/30/17 at 2:48 p.m. included, but was not limited to: .5. IDT (Interdisplinary Team) reviews risk factors upon admission and quarterly. a.) Care plan interventions will be implemented based on resident specific risk factors 10. Residents identified at risk for skin breakdown will have appropriate prevention interventions put into place a) A care plan will be developed specific to the resident's needs including prevention interventions This federal tag relates to Complaint IN 824. 3.1-40(a)(1)