Alden Valley Ridge Rehab & Hcc

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to treat a resident with respect and dignity during a meal.
This applies to 2 of 3 residents (R46 and R73) who were reviewed for feeding assistance in a sample of 32.
Findings included:
During an observation of the lunch meal at 12:27 PM on 06/04/2025, V37 (Certified Nursing Assistant), after completing assisting R73, without changing her sitting arrangement, overstretching to reach R46 to feed her by passing over R73.
On 06/05/2025 at 10:00 AM, V37 said she should have sat between V46 and V73, or changed R73 to a different table after feeding her. V37 stated that she understands her residents should be treated with respect and dignity.
The review of R46's EMR (Electronic Medical Records) showed that R46's diagnoses included Alzheimer's disease, dysphagia, psychosis, anemia, gastroesophageal reflux disease, and anxiety disorder. Minimum Data Set (MDS) dated [DATE] indicated R46's cognition is severely impaired, is not interviewable, and needs assistance for eating. R46's care plan dated 03/032025 indicated R46 pockets her food and eats slowly. R73's EMR ) showed that R46's diagnoses included Alzheimer's disease, psychosis, and anxiety disorder. MDS dated [DATE] indicated R73's cognition is severely impaired, is not interviewable, and needs assistance for eating.
06/0520/25 10:12 AM V2 (Director of Nursing) said all staff received services on residents' rights, and V37 should not be feeding any residents by passing over R73 to reach R43 to feed. V2 said all residents should be treated with respect and dignity.
The facility policy titled Dignity, dated 06/2023, in part, showed all residents should be treated with dignity and respect. The facility will promote care for residents that promotes and enhances their sense of well-being, level of life satisfaction, and feelings of self-worth and self-esteem .

Based on observation, interview and record review, the facility failed to safely secure an oxygen cylinder. to prevent from tipping over and potentially causing a fire or explosion.
This applies to 1 out of 3 residents (R143) reviewed for oxygen tanks in a sample size of 32.
The findings include:
On 6/3/2025 at 10:11 AM, 6/4/2025 at 9:05 AM and 6/4/2025 at 9:21 AM, a portable oxygen cylinder was unsecured on the floor. The oxygen cylinder was located on the head part on the right side of R143's bed and was half full. R143 said he does not use oxygen.
On 6/5/2025 at 8:35 AM , V2 (DON-Director of Nursing) said portable oxygen cylinders should be secured in a container to keep from tipping over. She said oxygen is flammable and if it tips over, may cause a fire or explosion.
R143's POS (Physician Order Sheet) showed no order for oxygen and his MDS (Minimum Data Sheet) dated 5/15/2025 documents that R143 has intact cognitive functions.
Facility's undated Policy and Procedure on Oxygen storage documents the following: Policy Oxygen will be stored in accordance with applicable regulations. Procedure: 1. All oxygen containers (compressed tanks and liquid cylinders) will be restrained while in storage.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure infection control practices.
This applies to 2 of 2 residents (R11 and R21) observed for infection control in a sample of 32.
Findings include:
1. On 06/03/25 at 3:25 PM, R21 was in the dining room reclined and slouched in a highback wheelchair. On the table in front of R21 was a brown semi-liquid substance with some dried areas that had the odor of excrement. R21 was playing with the brown substance using her left fingers, like finger painting on the table.
V4 (Activity Aide) brought R21 to the nurse's station and, without donning gloves, used a dry paper towel to wipe the right armrest and R21's right arm, which was covered in the brown substance. After wiping R21's arm and armrest, V4 threw away the soiled paper towel and, without performing hand hygiene, punched in the code to access the clean utility room. Without performing hand hygiene, V4 donned gloves to clean off the table in the dining room.
On 06/03/25 at 3:47 PM, V6 (Certified Nursing Assistant/CNA) and V7 (CNA) brought R21 to her room. Using her dry, soiled left hand, R21 was touching V7's bare right upper arm. V7 was unaware R21's hand was soiled. V8 (CNA) assisted V6 (CNA) in lifting R21 in the total body mechanical lift. V8 instructed R21 to hold the bar on the total body mechanical lift with her left hand. R21 held the bar briefly with her left hand. The mechanical lift sling under R21 was soaked and soiled. After removing R21's soiled pants and without removing her soiled gloves, V8 opened the closet door and removed clean pants. While V6 and V8 remained in the room, V7 (CNA) removed and disposed of her gloves, put hand sanitizer into her right hand and then opened the bedroom door before using the hand sanitizer. R21 was positioned lying on her right side while V6 was performing incontinence care with disposable personal wipes to clean a significant amount of soft, loose bowel movement. A line of dried stool was noted on R21's left buttock, lower hip, and upper outer thigh. V6 continued to clean the buttocks and placed her left gloved hand on the area of the dried stool. When V6 needed to change gloves, she reported that she did not have more gloves in the room and was required to obtain some. V6 removed the soiled gloves and left the room, touching the door handle with bare hands without washing her hands or performing hand hygiene. During this time, V8 continued to clean R21's left thigh. V6 returned, and both V6 and V8 continued providing incontinence care for R21. After completing incontinence care and without removing their soiled gloves, V6 and V8 applied a clean incontinence brief to R21. V8 then removed R21's soiled shirt and assisted in donning a clean shirt R21 without changing gloves. V8 removed her soiled gloves and without performing hand hygiene, grabbed the door handle, opened the door, walked to the shower room, punched in the code, opened the door, went into another room, punched in the code of the soiled utility room, opened that door, then got on the elevator saying she needed to go to the second floor to find a clean mechanical lift sling for R21. At 4:06 PM, as V6 and V8 prepared to transfer R21 from the bed to the wheelchair, R21's wheelchair had a dried, brown substance on the inside of its right armrest. Once R21 was in the wheelchair, V6 and V8 (CNAs) separated the soiled linens into a separate bag from the garbage, then placed both the garbage and the soiled linen bag onto the bedside table before closing each bag. V6 and V8 each removed their gloves but did not perform hand hygiene. V8 held the handrest of the highback wheelchair to propel R21 to the bathroom, and V6 carried the garbage in her bare hands to the soiled utility room. While cleaning R21's hands with a washcloth at the sink in the bathroom, V6 and V8 threw the soiled washcloths into the sink when they were done.
R21's EMR (Electronic Medical Records) showed R21 has diagnoses including hemiplegia and hemiparesis affecting the right side, dementia, contracture of the right elbow, aphasia, and tinea unguium (nail fungus). R21's Minimum Data Set (MDS) dated [DATE] showed R21's cognition was severely impaired. R21's care plan showed R21 had bowel and bladder incontinence with interventions including checking and changing R21 after incontinence episodes.
The facility's Hand Hygiene policy dated 10/2024 showed hand hygiene should be performed by washing hands with soap and water or using hand sanitizer to reduce the potential spread of pathogens. The policy includes performing hand hygiene prior to touching a resident when moving from a soiled body site to a clean body site of the same resident, after touching a resident or their immediate environment, and immediately upon removing gloves. Hand hygiene with soap and water should be performed when hands are visibly soiled or after any contact with blood, body fluids, or contaminated surfaces. Gloves or the use of perineal wipes are not substitutes for hand hygiene.
2. R11's EMR (Electronic Medical Records) showed R11 had diagnoses including vascular dementia, neuropathy, morbid obesity, tinea unguium, peripheral vascular disease, and contracture of the right and left knees. The MDS dated [DATE] showed R11's cognition was moderately impaired and was dependent on staff for toilet hygiene and bathing. R11 was always incontinent of bowel and bladder.
On 06/03/25 at 3:26 PM, At the other table, R11 was sitting in a wheelchair asking for help, saying he p***ed himself and needs to be changed. Underneath R11's wheelchair was a large puddle of liquid. The front of R11's pants was saturated with water. V4 and V5 (Activity Aides) were present in the room by the water cart.
On 06/03/2025 at 3:32 PM, V5 (Activity Aide) donned gloves and used a thin cloth to wipe up the liquid on the floor, but more liquid remained on the floor. At 3:33 PM, V4 (Activity Aide) walked through the wet trail of liquid/urine to clean up the dining room table. At 3:34 PM, R141 walked through the wet trail of urine in the dining room. R133 was in a wheelchair and propelled herself using her feet through the trail of urine. R133 was wearing socks only, no shoes. V5 then placed a towel over the area and left it.
On 06/03/2025 at 3:36 PM, V6 (Certified Nursing Assistant/CNA) wiped the urine off the floor with a towel only.
On 06/04/2025 at 3:32 PM, V4 (Activity Aide) stated that when a resident experiences an incontinence episode, they will notify the CNAs or nurses. V4 said they would clean up what they could and should wear gloves when cleaning it up. V4 said he should have had gloves on when cleaning R21 at the nurses' station, but there weren't any gloves available at the time. He cleaned the table with the purple top wipes but did not notify housekeeping to clean or disinfect the table or the floor on 06/03/2025, following R11 and R21's incontinence episodes. On 06/04/2025 at 4:07 PM, V3 (RN, MDS Coordinator) said the activity aide should put on gloves, then clean R21's hands and wheelchair with disposable cleaning wipes and paper towel.
On 06/04/2025 at 4:07 PM, V3 (RN, MDS Coordinator) said the staff needed to call housekeeping if there were body fluids, such as urine or stool, on the table or the floor. During incontinence care, the nursing staff should use hand sanitizer, don gloves, remove the resident's soiled incontinence brief, clean the resident, then remove gloves, perform hand hygiene, and don new clean gloves before placing a new incontinence brief on the resident. If staff members need to exit the room to retrieve any items, they should remove their gloves and perform hand hygiene before touching anything else. V3 stated that staff should not place garbage bags or soiled linen bags on the bedside table or any other surface.
On 06/04/2025 at 3:36 PM, V5 (Activity Aide) stated that if a resident had an incontinent episode that spilled onto any surfaces, they should call housekeeping to mop and clean the area. V5 stated on 06/03/2025 that they had only cleaned the floor with a towel and did not call housekeeping.
On 06/05/2025 at 11:05 AM, V9 (Housekeeping Supervisor) stated that if body fluids, such as a bowel movement or urine, were present on the floor or table, staff should call housekeeping to disinfect the area. The staff can clean up the area to remove the body fluids, but we would be the last ones to come in to disinfect the areas. Housekeeping uses Oxivir Five 16 to clean the table surfaces and Prominence to clean the floors.
On 06/05/2025 at 12:02 AM, V2 (Director of Nursing/DON), with V1 (Administrator) present, stated that if body fluids, such as stool or urine, were present on a table or floor, the staff should contact housekeeping to clean and disinfect the area. V1 (Administrator) said that, in theory, the staff can clean up the area as best they can, but they should still have housekeeping come in to clean up. V2 said hand hygiene should be performed after removing gloves, before touching another surface, and when going from a dirty to a clean area. If the gloves are visibly soiled, the staff should wash their hands with soap and water after removing them, or they can use hand sanitizer if the gloves are not visibly soiled. V2 said the staff should not place a garbage bag or a soiled linen bag on the floor or bedside table.

Based on observation, interview, and record review, the facility failed to practice safe food preparation, and properly label/date/seal/store food items in the facility kitchen.
This applies to all residents that receive oral nutrition and foods prepared in the facility kitchen.
Findings include:
The facility's Long-Term Care Facility Application for Medicare and Medicaid (Form CMS-Centers for Medicare and Medicaid Services-671) dated 6/3/25 documents that the total census was 162 residents. On 6/3/25 at 10:29 AM, V20 (Dietary Manager) said they only have 1 NPO (Nothing By Mouth) resident.
On 6/3/25 starting at 9:30 AM, the facility kitchen was toured independently and the following was found:
In Main Kitchen Area:
1.4 different prescription pills were found sitting on a plate on the food preparation counter. V25 (Dietary Aide) said the pills were hers.
2. The robo-coup blender and large plastic storage container of thickener with the lid off were located within splash distance of the handwashing sink.
In the walk-in cooler:
3. There was no room to walk in the cooler, there were four different carts on wheels stored in the cooler, one of the two tall rolling carts only had two small food items on it. The over-crowding of the cooler noted for potential to prevent proper air circulation and cooling of food items.
4. Small silver bin dated 5/19/25 with what appeared to be either tuna or chicken salad. Bin unlabeled.
5. A large silver bin or facility prepared egg salad dated 5/28/25. Salad looked wet and watery. At 10:26 AM V20 (Dietary Manager) said prepared salads are only good in the refrigerator for 1-2 days.
6. A half of a deli ham was dated 5/27/25. At 10:27 AM V20 said the ham is safe in the refrigerator for 4-5 days.
7. A white paper bag with unlabeled and undated plastic container of what appears to be a salsa like food item. Appears to be a personal staff or resident food item.
8. A plastic grocery store bag with 2 small plastic containers of liquid food items. Appears to be resident or staff personal food items inside. Food is unlabeled.
In the Dry Storage:
9. 4 large plastic bins on wheels labeled: Sugar, Rice, Oatmeal, and Flour, not dated.
10. 2-3lb (pound) 14 ounce cans of mushroom pieces and stems on circulation rack with large dents in the side of both cans.
11. 50lb bag of long grain white rice opened, not sealed, with a Styrofoam cup stored inside bag.
12. 1lb bag of jumbo marshmallows with a hole ripped in the side of the bag, not sealed or wrapped.
After the kitchen tour was completed independently on 6/3/25, around 10:15 AM, the tour was re-walked with V20 (Dietary Manager) and he was shown all of the above concerns found.
On 6/4/25 at 2:40 PM, V20 said the food in the walk-in cooler was not staff food, it was resident food brought in by family. V20 and V26 (Corporate Chef) said the facility does not have any policies that talk about storing scoops/cups in dry food items, storage of resident food brought in by family, storage of food/carts in walk-in cooler to allow for proper air circulation, any policies specific to how long prepared salads and/or deli meats are good for in the refrigerator, or labeling and dating of dry foods. V20 and V26 said all time/temperature controlled for safety foods are good in the refrigerator for 3-7 days.
On 6/5/25 at 10:38 AM, V20 said kitchen staff should not have their personal prescription pills out on the food preparation counter because of the risk of the pills getting mixed into resident foods. V20 said if a resident consumes a pill that is not their prescription it can harm the resident. V20 said the robo-coup and uncovered thickener container should not be stored within splash distance of the handwashing sink because of the risk of cross-contamination that can lead to resident illness. V20 said the sugar, rice, oatmeal, and flour bins should be dated for food safety and dented cans should be taken out of circulation because of the risk of botulism and resident death. V20 said a Styrofoam cup should not be stored inside of the rice bag because of the risk of cross-contamination and all opened food items should be resealed/wrapped to prevent contamination from dust, flies, or any kind of bacteria in the air. V20 said overcrowding in the walk-in cooler could affect the air circulation and food quality. V20 said all food items in the kitchen should be labeled and dated for food safety and quality. V20 said food brought in by resident families should not be stored in the walk-in cooler with other resident food because they don't know what is in the food and it can cause cross contamination.
The facility policy titled, Cleaning and Storing of Dishwares last revised 3/22 states, Policy: Dishwares will be cleaned and stored in a manner to decrease the risk of cross contamination. Purpose: To reduce the risk of cross contamination. Procedure: . 4.dishwares will be stored .in such a location as to prevent splash .
The facility policy titled, Food Storage Guidelines last revised 8/18 states, Policy: Food will be stored and used in an acceptable amount of time. Purpose: To reduce the risk of food borne illness. Procedure: . 3. Refrigerated TCS (Time/Temperature Controlled for Safety) food may be kept 3-7 days .
The facility's policy titled, Dented Cans last revised 3/24 states, Policy: Cans will be rejected if compromised. Purpose: To reduce the risk of food borne illness. Procedure: .2. Compromised cans will be stored on a shelf marked - do not use .
The facility's policy titled, Visitor Procured Food last revised 8/18 states, .Procedure: .2. Food & Nutrition Services will provide visitors a tip sheet on safe food handling. The tip sheet will highlight proper food handling practices .3. Food & Nutrition Services when assisting visitors with reheating or other preparation activities will use safe food handling practices .
The facility's undated tip sheet titled, Food Safety Information for Families and Visitors Tips to Keep Food Safe states, .Holding Foods: . Resident food should be in a tight container labeled with name, food item, and date it was prepared .Each facility has specialty designated area(s) where resident food .may be stored .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 6/3/25 at 10:33 AM, R87 was in bed. Her hair was not combed and greasy. R87 stated, It's been a while since they shampooed my hair. I would like my hair washed and combed.
R87's MDS dated [DATE] shows she is moderately impaired in cognition.
R87's care plan dated (5/12/25) shows she has an ADL functional performance deficit due to diagnosis of major depressive disorder, hypokalemia, iron deficiency anemia, hyperlipidemia, CHF (Congestive Heart Failure), GERD (Gastro-esophageal reflux disorder), and Osteoarthritis of hip. Intervention: Assist with ADL tasks as needed.
3. On 6/3/25 at 11:14 AM, R2 was in bed. She had hair on her chin and upper lip. R2 stated, I wanna be shaved. It doesn't look good.
R2's MDS dated [DATE] shows she is cognitively intact. R2's care plan dated (7/24/24) shows she has an ADL Self Care Performance deficit due to diagnosis of encounter for surgical aftercare following surgery. Intervention: Assist with ADL tasks as needed.
4. On 6/3/25 at 11:20 AM, R121 was in bed. Her hair was not combed and it was greasy. R121 stated, I didn't get a shower one day last week. They said they are short of CNA's (Certified Nursing Assistants). They don't wash my hair. I want it washed and combed.
R121's MDS dated [DATE] shows she is cognitively intact.
R121's care plan dated (7/26/24) shows she has an ADL Self Care Performance Deficit due to muscle weakness; decrease mobility related to diagnosis of rhabdomyolysis, lower back pain, abnormalities of gait, and radiculopathy/lumbar region. Intervention: Assist with personal hygiene as needed. Allow enough time for completion of ADL tasks. Do not rush the resident.
5. On 6/3/35 at 11:27 AM, R149 was in his room in bed. His nails on both hands were long and had a black substance underneath his nail tips. He stated he wanted his nails cut. He had a beard and he stated he wanted to be shaved. R149's MDS dated [DATE] shows he is cognitively intact.
R149's care plan dated (5/27/25) shows he has an ADL functional performance deficit due to spondylosis, major depressive disorder, COPD, anemia, mild neurocognitive disorder, and essential tremor. Interventions: Assist with ADL tasks as needed.
On 6/4/25 at 2:09 PM, V16 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) stated, Typically CNA's are responsible for shaving, providing nail care and washing/combing residents' hair.
Facility's policy titled Bath, Tub, or Shower (9/2020) shows: Policy: 1. To provide cleanliness and comfort to the resident.
Facility's policy titled Shaving The Resident (9/2020) shows: Purpose: To remove facial hair and improve the resident's appearance and morale.
Facility's policy titled Hair and Scalp Care (9/2020) shows: Purpose: 1. To clean hair and scalp. 3. To provide the resident with an attractive appearance and improve morale.
Facility's policy titled Nails (Care Of) (9/2020) shows: Policy: All residents will have clean, well-trimmed nails.
Based on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care to residents who require assistance with their ADLs.
This applies to 5 of 5 residents (R2, R21, R87, R121, R149) reviewed for ADL's in a sample of 32.
The findings include:
1. On 06/03/25 at 3:25 PM, R21 was in the dining room reclined and slouched in a high-back wheelchair. On the table in front of R21 was a brown semi-liquid substance with some dried areas that smelled like a bowel movement. R21 was playing with the brown substance using her left fingers like finger painting on the table. V4 (Activity Aide) told V3 (Registered Nurse/RN) that R21 needed to be cleaned up, showing V3 the brown substance. R21 was sitting in the wheelchair with a visible dried brown substance on the front of her pants and the side of the right armrest.
On 06/03/25 at 3:47 PM, V6 (Certified Nursing Assistant/CNA) and V7 (CNA) brought R21 to her room. The mechanical lift sling under R21 was soaked and soiled. After removing R21's soiled and wet pants, R21 was positioned lying on her right side while V6 was performing incontinence care with disposable personal wipes to clean a significantly soft, loose bowel movement. A line of dried stool was noted on R21's left buttock, lower hip, and upper outer thigh. V6 continued to clean the buttocks and placed her left gloved hand on the area of the dried stool. R21 had a small soft splint on her right hand. V6 and V8 said R21's hands were both cleaned. After removing the soft splint in R21's right hand, the soft splint was noted to be soiled with a brown substance. When R21's hands were wiped again with the personal disposable wipes, the wipes had shown brown soiling. As V6 and V8 prepared to transfer R21 from the bed to the wheelchair, this it was noteds that the wheelchair had a dried brown substance on the inside of its right armrest. V8 propelled R21 to the bathroom, and V6 carried the garbage in her bare hands to the soiled utility room. While cleaning R21's hands with a washcloth at the sink in the bathroom, the washcloths were visibly soiled. V6 and V8 threw the soiled washcloths into the sink when they were done.
R21's EMR (Electronic Medical Record) showed R1 has diagnoses including hemiplegia and hemiparesis affecting the right side, dementia, contracture of the right elbow, aphasia, and tinea unguium (nail fungus). The MDS (Minimum Data Set) dated 04/02/2025 showed R21's cognition was severely impaired. R21 had impairment of both the upper and lower extremities on one side. The MDS shows R21 was dependent on staff for toileting, bathing, dressing, and personal hygiene. R21 was always incontinent of bowel and bladder. The Care Plan indicated that R21 had an Activities of Daily Living (ADL) self-care deficit, requiring assistance with ADLs for hygiene, toileting, and bathing, with interventions that included two persons to perform these tasks. R21 required the use of a mechanical lift for transfers. The care plan showed R21 had bowel and bladder incontinence with a goal to be socially continent, clean, dry, and odor-free, with interventions including checking and changing R21 after incontinence episodes. R21 has impaired cognition and a deficit in the ability to self-understand due to a past cerebrovascular accident.
On 06/05/2025 at 2:52 PM, V2 (DON) stated that the facility doesn't have a policy on how often a resident needs to be checked or when the incontinence brief should be changed, but it should usually be done every two hours and as needed. If the resident is soiled or wet, they should be changed.

Based on observation, interview, and record review, facility failed to follow up with a Wound Consult ordered on 5/27/25 which resulted in the resident not being seen until 6/5/25. This failure resulted in a delay in Wound consult, assessment and implementation of new interventions for a pressure wound that deteriorated to an unstageable pressure injury.The findings include:R95's most recent pressure ulcer risk assessment (dated 04/22/25) showed R95 is at Mild Risk for developing pressure ulcers.On 06/03/25 at 9:51 AM, R95 was sleeping in bed. At 9:53 AM, V38 (CNA-Certified Nursing Assistant) said R95 had some redness on her backside. V38 said she was unsure if R95 had any wounds because she only cleans the skin around a dressing when providing incontinence care. At 10:07 AM, V32 (R95's POA-Power of Attorney) said that the facility had not mentioned anything about R95 having any pressure sores or open skin.On 06/04/25 at 2:10 PM, V16 (ADON-Assistant Director of Nursing/IP-Infection Preventionist) reviewed the EBP (Enhanced Barrier Precautions) list and said that R95 was not on the list since she does not have any wounds. V16 stated R95 has only exhibited some rash-like redness and was receiving treatment for Moisture-Associated Skin Damage (MASD).On 06/05/25 at 9:49 AM, V14 (RN-Registered Nurse) said that she had already changed R95's dressing earlier that morning. V14 stated that R95 did not have any pressure-related wounds and only had redness with some open skin. Per V14, R95's current wound treatment orders were only for the prevention of pressure injury. At 10:00 AM, V14 and V34 (CNA-Certified Nursing Assistant) turned R95 to her left side and V14 removed R95's undated dressing from her sacrum. The dressing was saturated with red and yellow fluid. R95's sacral area had a round, open area, and the wound bed was covered with thick, yellow, stringy slough adhered to it. The wound had a dark gray perimeter around the slough. V14 measured the wound and stated R95's wound was a pressure sore. At 10:15 AM, V14 stated that the last time she saw R95's wound was on 06/03/25 (2 days earlier) and she described it as a little open with little slough.V14's 6/5/25 1:24 PM wound assessment showed R95 has a sacral unstageable pressure ulcer with 90% slough and moderate serosanguinous discharge, with peri-wound measuring [in cm- centimeters] 6.2 cm x 4.2 cm with a pressure ulcer in the center that measured 3.2 cm x 3 cm with an undetermined depth. R95's EMR (Electronic Medical Record) did not include any previous wound assessments for R95's pressure ulcer.R95's POS (Physician Order Sheet) showed a 5/27/2025 order from V33 (PA- Physician Assistant) for a foam dressing and Medi-honey to R95's sacrum every day and evening for skin condition. The POS also included another order for in-house Wound Consult. No other new orders or interventions were included in R95's POS to address the unstageable pressure ulcer.On 06/06/25 at 11:03 AM, V33 (PA-Physician Assistant) said that on 05/27/25, facility staff notified her regarding a skin issue with R95's and she did not examine R95's skin herself and based her order for Medi-honey on the staff's description of R95's skin. V33 confirmed that Medi-honey is for pressure-related wounds and stated that she would have ordered a different topical treatment if R95 only had redness.On 06/05/25 at 12:30 PM, V31 (Wound Doctor) said that he had been in the facility on 06/03/25 and was not notified of R95's Wound Consult order and he did not see R95. V31 confirmed that Medi-honey is not an appropriate treatment for redness or MASD as it is typically used as a debridement agent for pressure-related wounds.R95's 12/14/23 care plan showed R95 with a potential alteration in skin integrity .previously with MASD to upper inner buttock/gluteal cleft area. R95's care plan had not been updated to include her actual pressure ulcer until 6/5/25, during the survey, and nine days after the Medi-honey order.The facility's policy on Prevention and Treatment of Pressure Injury and other Skin Alterations includes identifying residents at risk for developing pressure injuries, identifying the presence of pressure injuries and/or other skin alterations, and implementing preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through an individualized resident care plan. The policy also states that at least daily, staff should remain alert for potential changes in the skin condition during resident care .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to submit an initial resident abuse allegation to the Illinois Department of Public Health (IDPH) for an allegation of sexual abuse. This applies to 1 of 2 residents (R2) reviewed for abuse reporting.
The findings include:
Review of the facility's Abuse Policy, dated 09/20, stated in part, Initial Reporting of Allegations shall be completed immediately upon notification of the allegation. The written report shall be sent to the
Department of Public Health.
The EMR (Electronic Medical Record) shows R2 was admitted to the facility on [DATE] with multiple diagnoses, including dementia, cardiac disorders with a pacemaker, venous thrombosis, type 2 dialysis, and chronic kidney disease, R3's MDS (Minimum Data Set) dated 09/11/2024 shows R3 is cognitively severely impaired requires two staff assistance for mobility and transfer.
The facility investigation report dated 11/04/2024 showed R3 (R2's family member), who is on the second floor, reported to V4 (Director of Memory Care) that some man came to R2's room with his hot dog hanging in between his leg and showed it to her. V1 (Administrator) and V4 met with R2 and investigated the allegation. The allegation was unfounded.
On 12/09/2024 at approximately 11:00 AM, V4 said she reported to V1 when R3 reported the allegation and they investigated the incident. V4 said R2 could not converse in person or over the phone, and there was no contact between R2 and R3 due to the infection control lockdown. V4 said the allegation was not substantiated, so they did not report the allegations to the State Agency.
On 12/06/2024 at 3:00 PM, V3 (Director of Nursing) said R2 was in memory care, and R3 was on the second floor. V1 and V3 said R2 is unable to hold any conversation, and R3 is delusional and paranoid with multiple psychiatric problems. V3 said there was no contact between R3 and R2 during the allegation time since R3 was isolated due to COVID-19 and the second floor was on lockdown. V2 said that after a week, R3 reported the allegation to the police and the police investigated with no findings. V1 and V3 said it had slipped from their mind to report to IDPH and acknowledged that they should have reported it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. R114's admission Record shows he was admitted to the facility on [DATE] with diagnoses including legal blindness, major depressive disorder, and depression.
R114's Care Plan revised January 8, 2024 shows, [R114] has potential for alteration in skin integrity related to frequent falls, syncope and collapse, muscle weakness, unsteadiness on feet, cognitive communication deficit and bowel and bladder incontinence.
On August 19, 2024 at 9:56 AM, R114 was asleep in someone else bed. V4 (CNA) transferred R114 from the bed to his wheel chair with no gait belt. R114 was unsteady on his feet and was hunched over during the transfer. V4 held R114 by the back of his pants while transferring him.
4. R130's admission Record shows she was admitted to the facility on [DATE] with diagnoses including dementia, anxiety disorder, abnormalities of gait and mobility, and muscle weakness.
R130's Care Plan revised on August 1, 2024 shows R130 is at risk for falls due to diagnoses of dementia, high blood pressure, depression, and benign paroxysmal vertigo.
On August 19, 2024 at 11:42 AM, R130 let V3 (CNA) know that R130 had to go to the bathroom. V3 wheeled R130 to the bathroom via her wheel chair. V3 pulled R130 up via the back of R130's pants. V3 had a transfer belt around V3's waist. V3 sat R130 onto the toilet. When R130 was done using the bathroom, V3 stood R130 up and wiped R130's peri area. V3 pulled R130's incontinence brief and pants up and then transferred R130 back into her wheel chair. R130 was unsteady on her feet.
On August 20, 2024 at 1:32 PM, V14 (CNA) said staff should use a gait belt when transferring resident for the resident and staff safety.
The facility's Transfer Techniques dated February 2022 shows, Purpose: To safely transfer the resident from bed to chair or from one location to another. Transfer from bed to wheel chair: Have resident sit on the edge of the bed with feet uncrossed and resting on the floor. He/she may use this as an opportunity to practice sitting balance. Put on gait belt and shoes.
Based on observation, interview, and record review, the facility failed to ensure residents were transferred and/or repositioned in a safe manner for 4 of 33 residents (R69, R66, R114, and R130) reviewed for safety and supervision in the sample of 33.
The findings include:
1. On 8/19/24 at 10:50 AM, V10 (Certified Nursing Assistant/CNA) and V11 (CNA) finished changing R69. V10 was on one side of R69's bed and V11 was on the other side. V10 and V11 each hooked their respective arms under R69's underarms and pulled R69 up in bed. Then, V10 and V11 proceeded to pull R69 forward by R69's underarms using the same method described above to reposition R69's pillow.
On 8/19/24 at 11:24 AM, V16 (CNA) said when boosting a resident in bed there should be a person on each side of the bed and they should use the bed pad or flat sheet to pull the resident up in bed. V16 said it is not safe to pull a resident up by their arms.
R69's admission Record shows she is a [AGE] year old female. R69's current care plan provided by the facility shows R69 has limitation in range of motion and is to receive passive range of motion to both upper and lower extremities. R69's current care plan provided by the facility shows R69 has the potential for hemorrhage or bruising and impaired skin integrity due to use of anticoagulant therapy and a history of decreased mobility. Staff are to instruct R69 to put her arms into a self-hugging position when being boosted up in bed and an assistive device is to be used to decrease friction to lift (do not slide) R69 for bed mobility.
2. On 8/19/24 at 11:02 AM, V16 was in the bathroom with R66. V16 assisted R66 off the commode and pulled up R66's pants and transferred R66 to her wheelchair without using a gait belt.
R66's admission Record dated 8/21/24 shows R66's diagnoses include, but are not limited to, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. R66's Minimum Data Set, dated [DATE] shows R66 has limitation that interfered with daily functions or placed resident at risk of injury to an upper extremity and a lower extremity, is dependent on staff for toileting hygiene, and requires substantial/maximal assistance with lower body dressing, sit to stand, and toilet transfers.
The facility's Incidents by Incident Type list dated 8/20/24 shows R66 fell on 5/18/24 and again on 8/7/24.
The facility's Transfer Techniques Policy dated 2/2022 shows the purpose is to safely transfer the resident from one location to another and staff are to place a gait belt around the resident's waist during the transfer.

Based on observation, interview, and record review, the facility failed to provide a resident with privacy during activities of daily living (ADL) care for 1 of 33 residents (R17) reviewed for privacy in the sample of 33.
The findings include:
R17's admission Record shows he was admitted tot he facility on September 7, 2007 with diagnoses including dementia, non pressure chronic ulcer of skin, depressive episodes, and kidney disease.
R17's Care Plan initiated on June 10, 2024 shows R17 is incontinent of bowel and bladder.
On August 19, 2024 at 9:56 AM, V4 and V5 (Certified Nursing Assistants/CNA) were preparing to provide incontinence care for R17. V5 CNA folded R17's incontinence brief downward in between in legs while he was laying on his back. R17's curtain was not closed and R17's roommate was in his bed, facing R17, and talking with V4 and V5. R17's front peri area was exposed.
On August 20, 2024 at 1:32 PM, V14 CNA said resident's curtains should be closed during incontinence care so the resident has privacy.
The State of Illinois Residents' Rights revised November 2018 shows, You have a right to privacy and confidentiality of your personal and medical records. Your medical and personal care are private. Facility staff must respect your privacy when you are being examined or given care.

Based on observation, interview and record review the facility failed to ensure staff-dependent residents were provided incontinence care for 2 of 33 residents (R34, R51) reviewed for activities of daily living (ADL's) in the sample of 33.
The findings include:
1. R34's current care plan showed R34 was dependent on staff for incontinence care and toileting. R34 was cognitively intact.
On 8/19/24 at 9:32 AM, R34 was in bed, eating breakfast. R34 stated, They really treat me good here but, lately it seems like it's taking longer for someone to come change me. There have been times that I have waited over five hours for someone to come. I wear a brief. This last time someone changed me today was around 4 AM. At 9:38 AM, V12 (Certified Nursing Assistant/CNA) entered R34's room to provide cares. V12 stated this was her first time providing incontinence care to R34 for the day. V12 removed R34's brief which was saturated with urine. Urine had leaked out of R34's brief, onto R34's sheet and mattress.
2. R51's current care plan showed R51 was dependent on staff for incontinence care and incontinent of bowel and bladder related to his diagnoses of dementia, impaired cognition, and cerebral infarction (stroke) with left arm and leg hemiplegia (paralysis). The plan showed, Provide incontinence care after each incontinent episode.
On 8/19/24 at 9:53 AM, R51 was in bed. A strong foul odor of urine and stool was noted in the room. At 9:55 AM, V13 (CNA) entered R51's room. V13 (CNA) was asked about the odor in R51's room, V13 stated, I don't know what that is. I last changed him at 7 AM. V13 repositioned R51 to check his incontinence brief. R51's brief was saturated with urine and stool. Urine and stool had leaked out of R51's brief, onto R51's bedding. R51's buttocks appeared bright pink. V13 stated incontinence care should be provided every two hours to resident's that require staff assistance or are dependent on staff for incontinence care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to have a physician ordered treatment in place for a resident with open areas to his buttocks for 1 of 33 residents (R17) reviewed for quality of care in the sample of 33.
The findings include:
R17's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, non pressure chronic ulcer of skin, depressive episodes, and kidney disease.
R17's Care Plan that was provided by the facility did not include any skin issues on R17.
On August 19, 2024 at 9:56 AM, V4 (Certified Nursing Assistant/CNA) and V5 (CNA) provided incontinence care to R17. When R17 was turned onto his side, there was multiple open areas noted to R17's buttocks. There was spots of dried blood on R17 incontinence brief. R17 said Ow! each time V5 wiped R17's buttocks. V5 said she was going to tell the nurse about R17's buttocks. There was no dressing or treatment in place to R17's buttocks.
On August 20, 2024 at 1:07 PM, V14 (CNA) and V3 (CNA) transferred R17 back into his bed from his chair to perform incontinence care on him. R17's penis was raw and bright red. R17 said OW! as V3 wiped the tip of R17's penis. V3 turned R17 onto his side. There was no dressing to R17's buttocks. R17's buttocks area still had open areas. V3 got R17's nurse, V15 (Registered Nurse/RN). V15 came into R17's room and placed zinc to R17's buttocks. V3 showed V15 R17's penis. V15 said, Oh . V15 was not aware of the sores to R17's penis. V15 said she was going to contact the hospice nurse.
On August 20, 2024 at 1:39 PM, V15 said she did not know that R17 had an order for a dressing to his buttocks. V15 said that night shift places the dressing onto R17's buttocks. V15 said a foam dressing is used for extra protection.
R17's Order Summary Report dated August 19, 2024 shows an order dated August 5, 2024 for optifoam dressing apply to right buttocks every evening shift for skin condition and apply to left buttocks every evening shift for skin condition. There's an order dated May 30, 2024 optifoam adhesive island apply to left buttock topically as needed.
R17's skin/wound progress note dated August 19, 2024 shows, right buttocks slightly red. R17's skin/wound progress note dated August 21, 2024 shows R17 has excoriation to his buttocks.
The facility's Prevention and Treatment of Pressure Injury and Other Skin Alterations dated March 2, 2021 shows, Implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan. Revise Care Plan approaches as needed based on resident's response and outcomes.

Based on observation, interview and record review the facility failed to ensure pressure injury treatments and pressure relieving interventions were in place for 1 of 7 residents (R9) reviewed for pressure injuries in the sample of 33.
The findings include:
R9's care plan dated 10/19/2018 showed R9 was at risk for developing pressure injuries due to her history of a previous pressure injury to her left buttock, inability to reposition herself, and history of bowel incontinence. The care plan showed R9 had diagnoses of multiple sclerosis, spinal stenosis, and quadriplegia. The plan showed R9 was cognitively intact.
R9's wound note dated 2/21/23 showed a Stage III pressure injury to R9's left buttock had resolved and was completely healed.
R9's progress note dated 6/5/24 showed an open area and redness was identified to R9's left buttock.
R9's wound note dated 6/11/24 showed R9 was seen by the facility's wound physician for a re-opened Stage III pressure injury, to her left buttock, that measured 9 centimeters (cm) x 9.5 cm x 0.2 cm.
R9's wound note dated 8/6/24 showed R9's left buttock Stage III pressure injury measured 5.7 cm x 7 cm x 0.2 cm. The note showed to monitor R9 for incontinence and change after each episode. The note showed staff were to reposition R9 every two hours and offload R9's heels with a pillow or heel boots while in bed. The note showed facility staff were to apply treatment ointments and a foam dressing to R9's pressure injury once a day and as needed.
On 8/19/24 at 10:03 AM, R9 was in bed, lying on her right side. R9's heels rested directly on mattress of her bed. R9 was alert and cognitively intact. R9 stated she could not lay on her left side in bed due to a wound on her left buttock. When asked about her wound, R9 stated, I got the wound here because they didn't reposition me. I can't move myself because I have MS (multiple sclerosis).
On 8/20/24 at 8:45 AM, R9 was lying in bed. R9's heels rested directly on the mattress of her bed. R9 stated she was seen by the facility's wound physician around 7 AM that morning. R9 stated, I don't have a dressing on my wound. They never put one back on after the doctor looked at it. At 8:47 AM, V10 (Certified Nursing Assistant/CNA) and V11 (CNA) entered R9's room to provide cares. V10 removed R9's incontinence brief as R9 was incontinent of stool. No dressing was noted to the large, circular, open wound to R9's left buttock. Stool was noted in and around the wound. As V10 cleansed R9's buttocks, R9 complained of pain when V10 wiped R9's left buttock wound. V10 and V11 placed a clean incontinence brief on R9 with no dressing in place to her buttock wound. A scant amount of bleeding was noted from the wound. As R9 was repositioned in bed, she complained of pain to her left buttock. R9 stated, It just hurts because there is no dressing on there. V10 and V11 exited R9's room.
On 8/20/24 at 8:54 AM, V9 (Registered Nurse/RN) stated if staff observe that a resident's wound does not have a dressing in place, staff are to report it to a nurse immediately to have a dressing put in place.
On 8/20/24 at 10:47 AM, V8 (previous Wound Nurse/RN) stated R9 was at risk for developing pressure injuries due to her history of previous pressure injuries and her diagnosis of multiple sclerosis. V8 stated, (R9) can't reposition herself. She has very limited movement. She can only move her left hand to pick up a cup. She had Stage III pressure injury to her left buttock before. She has no wounds to her heels, but they should be offloaded with a pillow. When V8 was asked what caused R9's left buttock pressure injury to reopen, V8 stated, Her skin is fragile, but I would say it was also likely because of infrequent repositioning and not making sure peri-care isn't done right away.
On 8/20/24 at 12:46 PM, R9 was in bed, being fed by staff. R9 stated staff placed a dressing on R9's left buttock pressure injury sometime after 10 AM that morning. When R9 was asked if she ever refused to allow staff to apply a dressing to her wound on the morning of 8/20/24, R9 stated, No I didn't.
The facility's Prevention and Treatment of Pressure Injury and other Skin Alterations policy dated 3/2/21 showed it was the facility's policy to identify the presence of pressure injuries . implement preventative measures and appropriate treatment modalities for pressure injuries and/or other skin alterations through individualized resident care plan .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to perform peri care in a manner to prevent urinary tract infection and failed to maintain the catheter bag below the level of the bladder to prevent infection for three of three residents (R33, R19, R9) reviewed for incontinence care and catheter care in the sample of 33.
The findings include:
1. R19's admission Record shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, dementia, anxiety disorder, and heart failure.
R19's Care Plan revised on July 8, 2024 shows R19 experiences bowel and bladder incontinence due to dementia, chronic kidney disease stage three, diabetes, atrial fibrillation, and anxiety.
R19's Medication Administration Record shows she has been treated for a urinary tract infection in the past.
On August 19, 2024 at 10:56 AM, V6 (Certified Nursing Assistant/CNA) and V4 (CNA) provided incontinence care on R19. R19 had a large amount of stool in her incontinence brief. R19 was turned on her side and V6 wiped the stool from R19's buttocks. R19 was then laid back onto her back. There was a moderate amount of stool noted to R19's front peri area. V6 wiped the stool from R19's peri area from back to front multiple times.
2. R33's admission Record shows she was admitted to the facility on [DATE] with diagnoses including malnutrition, palliative care, morbid obesity, depression, anxiety disorder, and dementia.
R33's Medication Administration Record shows she has been treated with antibiotics for a urinary tract infection in the past.
On August 19, 2024 at 10:11 AM, V4 (CNA) performed incontinence care on R33. There was stool noted in R33's buttocks. V4 wiped R33's buttocks then laid her onto her back to perform peri care to R33's front. There was a large amount of stool noted to R33 front peri area. R33 had an urinary catheter in place. V4 wiped the stool in R33's front peri area from back to front multiple times, using the same wet wipe.
On August 20, 2024 at 1:32 PM, V14 (CNA) said stool should be wiped from front to back on residents to prevent infection.
The facility's Perineal Care policy dated September 2020 shows, Purpose: To prevent infection and odor. Female Perineal Care: Separate the labia. Clean downward from front to back with one stroke.
3. R9's current care plan showed R9 required the use of a supra-pubic urinary catheter due to her diagnosis of obstructive and reflux uropathy. The plan showed, keep (catheter) tubing free of kinks and monitor (tubing) for patency .
On 8/20/24 at 8:45 AM, R9 was lying in bed, covered with a blanket. No urinary catheter collection bag was noted hanging off either side of R9's bed. At 8:47 AM, V10 (CNA) and V11 (CNA) entered R9's room to provide cares. As V10 (CNA) removed the blanket off R9, R9's urinary catheter collection bag lay next to R9's left leg, on the bed. Urine was noted in the tubing of R9's catheter tubing. As V10 and V11 repositioned R9 in bed, a back-flow of urine was noted in the tubing of R9's catheter. Once cares were completed on R9, V10 (CNA) hung R9's urinary catheter collection bag off the side of R9's bed, allowing the urine in the catheter tubing to drain into the collection bag.
On 8/20/24 at 8:54 AM, V9 (Registered Nurse) stated a resident's urinary catheter collection bag should be hanging below the level of the resident's bladder to make sure the urine is able to drain out. If the urine can't drain out, it can cause pain or infection.

Based on observation and interview, the facility failed to ensure a resident's tube feeding bag was labeled with the time it was initiated for 1 of 4 residents (R60) reviewed for tube feeding in the sample of 33.
The findings include:
On 8/19/24 at 9:49 AM, R60 was lying in bed with her tube feeding infusing. R60's tube feeding formula bag was dated 8/18/24, however, no time was documented.
On 8/20/24 at 10:56 AM, V17, (Registered Nurse), said the G-tube bags should be labeled with the formula, dose, date and time since the bag and the tubing are good for 24 hours before they need to be changed.
On 8/21/24 at 11:07 AM, V2, (Director of Nursing), said the tube feeding bag is good for 24 hours once hung; it needs to be labeled with the date and time it was started.
R60's Order Summary Report dated 8/19/24 shows an order to infuse tube feeding at 60 ml (milliliters)/hour for 24 hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R65's Facesheet printed on 8/21/24 showed R65 to be an [AGE] year old male resident readmitted to the facility on [DATE] with diagnoses which include: acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease with acute exacerbation, and pneumonitis due to inhalation of food and vomit.
On 8/19/24 at 11:00 AM, R65 was in his room completing a nebulizer treatment. R65 had a mediation package with 2 DuoNeb doses, 1 dose of Budesonide suspension, and 1 Fluticasone aerosol dispenser which R65 placed in the middle drawer of his nightstand. R65 stated he had made a deal to take the medications himself since he takes 4 DuoNeb and 2 Budesonide treatments a day. R65 stated the nurse will sometimes listen to my lungs in the morning, but they don't do it with every treatment. I have been doing these myself just after I was in the hospital with pneumonia.
R65's Order Summary printed on 8/21/24 showed an order for Budesonide Inhalation Suspension 1 milligram/milliliter (mg/ml) inhale orally two times daily, DuoNeb Solution 0.5-2.5 (3) mg/3ml inhale orally via nebulizer four times daily (and as needed), and Fluticasone Furoate Aerosol Powder Breath Activated 200 micrograms per activation inhaled orally one time a day.
On 8/20/24 at 9:35 AM, V21 (RN) stated if a resident is able to give themselves medications they need to be assessed. R65 has been doing his own nebulizer treatments for a while.
R65's medical record showed no Self Administration Assessments prior to 8/20/24, and no Care Plan entries for Self administration of medications prior to 8/21/24.
3. R158's Facility assessment dated [DATE] showed R158 is a cognitive [AGE] year old female who was readmitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease with acute exacerbation and acute and chronic respiratory failure with hypoxia.
On 8/19/24 at 11:20 AM, R158 was sitting on her bed self administering a nebulizer treatment. R158 had 3 unopened nebulizer medication vials (Albuterol) on the night stand. R158 stated I am very independent. It is just easier to have a few of these (treatments) in my room to just do them instead of tracking down a nurse to get one. Since restarting them I usually need 3 or 4 treatments a day. I knew how to use a nebulizer from before, but no one has ever came to teach me how to use it or had me sign anything saying I knew how.
R158's Order Summary printed on 8/21/24 showed R158 has an order for Albuterol Sulfate Inhalation Nebulization Solution 2.5mg/3ml. Inhale orally every 4 hours as needed for wheezing or shortness of breath.
R158's medical record showed no Self Administration Assessments prior to 8/20/24, and no Care Plan entries for Self administration of medications prior to 8/21/24.
On 8/21/24 at 1:20 PM, V2 (Director of Nursing) stated a resident needs to be assessed to be able to self administer medications.
The facility's Self-Administration of Medications Policy dated 9/2020 showed a resident will not be permitted to administer or retain medications in their rooms unless so ordered by the attending physician, assessed for their cognitive, physical, and visual ability to self-medicate, and approved by the care planning team. This Policy also showed a resident able to self-administer medications will be placed on a training program which includes: Self-medication assessments completed initially and quarterly, a plan of care with quarterly documentation, and the completion of a Self-Medication Daily Flow Sheet.
Based on observation, interview and record review the facility failed to ensure medications were dispensed according to standards of practice. The facility failed to ensure residents were assessed to self-administer medications. These failures apply to 3 of 33 residents (R9, R65, R158) reviewed for medication administration in the sample of 33.
The findings include:
1 .On 8/20/24 at 8:45 AM, R9 was lying in bed. A medication cup, containing sixteen different pills of size and color, was on the table directly in front of R9. When R9 was asked about the pills, R9 stated, I think those are my morning medications. No nursing staff were noted in R9's room.
On 8/20/24 at 8:54 AM, V9 (Registered Nurse/RN) stated, No residents on the second floor (R9's floor) can self-administer their medications or have meds in their room. We must watch them take their medications to make sure they take them or don't choke. We would need a physician order to let a resident administer their own medications.
On 8/20/24 at 1:38 PM, V1 (Administrator) stated, R9 had never been assessed to self-administer her medications.
R9's August 2024 Order Summary Report showed no physician order to allow R9 to self-administer her medications or to keep medications in her room.
The facility's Medication Administration: General Guidelines policy dated 1/2022 showed, All medications shall be administered as prescribed by licensed personnel authorized to do so in accordance with standard nursing practice and current regulations. Residents are permitted to self-administer medications when specifically authorized by the physician and if determined able in accordance with policies and procedures for self-administration of medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R33's admission Record shows she was admitted to the facility on [DATE] with diagnoses including malnutrition, palliative care, morbid obesity, depression, anxiety disorder, and dementia.
R33's Order Summary Report dated August 19, 2024 shows an order for indwelling urinary catheter and EBP (Enhanced Barrier Precautions) for device care or use of urinary catheter.
R33's Care Plan initiated March 5, 2024 shows, Enhanced barrier Precautions will be implemented during high contact resident care activities.
On August 19, 2024 at 10:11 AM, there was a sign outside of R33's door that showed, Enhanced Barrier Precautions Everyone Must: Wear gloves and a gown for the following High-Contact Resident Care Activities. Dressing, changing linens, providing hygiene, and changing briefs or assisting with toileting. V4 (Certified Nursing Assistant/CNA) provided incontinence care to R33. V4 did not wear a gown while she changed R33's linens or changing her incontinence brief.
The facility's Enhanced Barrier Precautions dated December 14, 2023 shows, Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDRO) in nursing homes. As well as to prevent multi-drug resistant organism acquisition of those with an increased risk of acquiring MDROs including resident with a chronic wound or an indwelling medical device.
6. R17's admission Record shows he was admitted to the facility on [DATE] with diagnoses including dementia, non pressure chronic ulcer of skin, depressive episodes, and kidney disease.
On August 19, 2024 at 9:56 AM, V4 (CNA) and V5 (CNA) provided incontinence care for R17. There was a large amount of urine and stool in R17's incontinence brief. V5 wiped R17's front peri area, then turned R17 onto his side. V5 then wiped R17's buttocks, applied cream to R17's buttocks. V5 turned R17 back onto his back and then touched R17's pillow under his head. V5 did not change her gloves or perform hand hygiene.
7. R19's admission Record shows she was admitted to the facility on [DATE] with diagnoses including hemiplegia, dementia, anxiety disorder, and heart failure.
R19's Care Plan revised on July 8, 2024 shows R19 experiences bowel and bladder incontinence due to dementia, chronic kidney disease stage three, diabetes, atrial fibrillation, and anxiety.
On August 19, 2024 at 10:56 AM, V6 (CNA) and V4 (CNA) provided incontinence care on R19. V6 folded down R19's incontinence brief in between R19's legs while she was laying on her back. V6 then helped R19 turn onto her left side. V6 wiped the stool from R19's buttocks, placed a new incontinence brief underneath R19, then turned R19 back onto her back. V6 then wiped the stool from R19's front peri area, removed R19's gown, placed clean pants and a clean blouse onto R19. V6 did not change her gloves or perform hand hygiene.
On August 20, 2024 at 1:32 PM, V14 (CNA) said gloves should be changed after touching dirty items and before touching clean items to prevent infection.
The facility's Hand Washing and Hand Hygiene policy dated June 4, 2020 shows, Appropriate hand hygiene is essential in preventing the spread of infectious organisms in healthcare settings. Hand hygiene must be performed after touching blood, body fluids, secretions, excretions, and contaminated items.
Based on observation, interview, and record review the facility failed to ensure a COVID-19 positive resident remained in isolation, failed to ensure a resident identified as a close contact with COVID-19 symptoms was wearing a mask, failed to ensure staff donned personal protective equipment (PPE) when providing care for a resident on enhanced barrier precautions (EBP), failed to ensure residents with feeding tubes were placed on EBP, and failed to perform hand hygiene and change gloves during pericare to prevent cross contamination. These failures apply to 8 of 33 residents (R44, R91, R9, R60, R57, R33, R17, R19) reviewed for infection control in the sample of 33.
The findings include:
1. R44's Facesheet printed on 8/21/24 showed R44 to be a [AGE] year old female resident readmitted to the facility on [DATE]. This document showed a new diagnosis of COVID-19 on 8/12/24.
R44's COVID-19 Results Worksheet showed R44 being COVID-19 positive on 8/12/24.
R44's Order Summary printed on 8/21/24 showed an order for Isolation: contact and droplet precautions due to positive COVID-19 times 10 days ending on 8/22/24.
On 8/19/24 at 11:45 AM, R44's room doorway had a contact/droplet isolation sign on it and a PPE cart next to the doorway. R44's room is near the opposite end of the hallway from the nurses station.
On 8/19/24 at 1:30 PM, R44 was in her wheelchair near the nurses station area raising her voice to the staff, she was looking for her ranch dressing. R44 had several staff members pass her while she was in the hallway waiting. None of the staff members attempted to redirect R44 back down the hall toward her room until they had found the salad dressing bottle.
On 8/19/24 at 2:00 PM, R44 was in her room. During the interview, R44 had a repeated cough and congestion symptoms.
On 8/20/24 at 1:40 PM, V2 (Director of Nursing) stated if a COVID-19 positive resident is out of their room the staff should attempt to redirect the resident back to their room as soon as possible. The first positive resident we had was on 7/21/24, and we had the 3 new positives on 8/4/24.
The facility's undated COVID-19 policy showed residents COVID-19 transmission based precautions should have transport and movement outside their room limited to medically essential purposes.
2. A facility roster dated 8/19/24 showed R40 and R91 resided in the same room in the facility.
R40's Communication Form and physician orders dated 8/20/24 showed R40 was placed on strict contact/droplet isolation for possible COVID exposure as R40 had developed COVID-like symptoms of a congested, productive cough. The form showed R40 refused to be tested for COVID.
On 8/20/24 at 9:11 AM, a droplet/contact isolation sign hung on the door of R40 and R91's room. V9 (Registered Nurse/RN) entered the room to administer medications to R91 but R91 was not in his room. R40 was in bed, actively coughing. When V9 was asked about R40's cough, V9 stated R40 had developed a cough and COVID-like symptoms overnight so was placed on droplet/contact isolation. V9 stated R40 had refused any COVID testing. At 9:14 AM, V9 (RN) found R91 seated in the second floor dining room, eating breakfast with thirteen other residents noted in the room. R91 wore no protective mask. V9 administered medications to R91.
On 8/21/24 at 9:52 AM, V2 (Director of Nursing) stated, (R91) should be wearing a mask when he is out of his room. Any resident that has had close contact with someone exhibiting COVID symptoms are tested but don't need to be isolated if negative with no symptoms. They do need to wear a mask when out of their room for ten days post-exposure.
The facility's COVID-19 policy (undated) showed residents who are not symptomatic but have had close contact with someone who has COVID-19 do not need to be isolated but do need to wear source control (masks) when out of their rooms for ten days post-exposure.
3. R9's physician order dated 8/22/23 showed R9 was on Enhanced Barrier Precautions (EBP) do to the placement of her urinary catheter.
On 8/20/24 at 8:47 AM, an EBP isolation sign hung on the door to R9's room. V10 (Certified Nursing Assistant/CNA) and V11 (CNA) entered R9's room without donning protective gowns, only masks and gloves. V10 and V11 provided incontinence care to R9 which included cleansing R9's left buttock pressure injury and the handling of R9's urinary catheter.
On 8/21/24 at 11:01 AM, V2 (Director of Nursing) stated any resident with a urinary catheter, gastrostomy tube, or wounds are to be placed on Enhanced Barrier Precautions (EBP). V2 stated staff are to wear gowns, gloves, and masks when providing cares to residents on EBP.
4. R57's Order Summary Report dated 8/19/24 shows an active order for EBP for device care or use of feeding tube. On 8/19/24 at 9:43 AM, R57 was lying in his bed with tube feeding infusing. There were no signs on his door or in his room regarding enhanced barrier precautions and no PPE was located outside of his room.
R60's Order Summary Report dated 8/19/24 shows an active order for EBP for device care or use of feeding tube. On 8/19/24 at 9:53 AM, R60 was lying in her bed with tube feeding infusing. There were no signs on her door or in her room regarding enhanced barrier precautions and no PPE was located outside of her room.
On 8/21/24 at 10:50 AM, V2, Director of Nursing, said they follow the CDC guidelines for infection prevention/isolation precautions.
According to the CDC (Centers for Disease Control and Prevention) website dated 6/28/24 https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html?CDC_AAref_Val=https://www.cdc.gov/hai/containment/faqs.html Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. Generic signs that instruct individuals to speak to the nurse are not adequate to ensure Precautions are followed.
According to the CDC website (updated 7/12/22) https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html, residents with an indwelling medical device (including a feeding tube) are to be placed on EBP, regardless of MDRO colonization status.

Based on observation, interview and record review the facility failed to ensure symptomatic residents were immediately isolated and tested for COVID-19 to prevent to spread of infection and failed to ensure appropriate personal protective equipment was used when entering a contact/droplet isolation room for 5 of 31 residents (R10, R83, R100, R115 and R121) reviewed for infection control in the sample of 31.
The findings include:
1. On 9/11/23 at 9:30 AM, R100 was laying in bed coughing and had a hoarse voice. R100 said that he had been coughing since yesterday (9/10/23). V17 (Certified Nursing Assistant) provided incontinence care and a transfer for R100. R100 was not on isolation.
On 9/12/23 at 1:23 PM, there was a sign outside of R100's room that showed that he was on contact droplet isolation. The sign showed, Droplet Precautions-Everyone must: .Make sure their eyes, nose and mouth are fully covered before room entry [picture of a person with a faceshield on and a picture of a person with goggles on] .Remove face protection before room exit. There was an isolation cart outside of R100's room. This cart did not contain any faceshields or goggles. V17 donned a surgical mask, gloves and gown before entering the room. V17 did not apply any eye protection.
On 9/12/23 at 9:20 AM, V17 stated that she started getting sick last night with a cough and congestion. V17 stated, Everyone is sick.
On 9/12/23 at 1:09 PM, V18 (CNA) said that when entering a contact/droplet isolation room staff should put on gloves, gown and a surgical mask.
R100's Nursing Notes dated 9/7/23 at 7:13 AM shows, Resident w/ (with) on and off cough, runny nose .DON (Director of Nursing) updated. Will monitor.
R100's Nursing Notes dated 9/11/23 at 1:45 PM shows, Resident noted with hoarse voice and occasional dry cough .Rapid COVID 19 test negative, place on contact/droplet isolation due to COVID-19 symptoms .
On 9/12/23 at 11:53 AM, V5 (Infection Prevention Nurse) said that symptoms of COVID 19 include: sore throat, cough, runny nose, increased weakness, confusion, muscle aches and fever. V5 said that a resident should be immediately place on contact/droplet isolation if they have any COVID-19 symptoms. V5 said that the resident should then be tested for COVID-19. V5 said that the facility is only currently using rapid COVID tests and not doing PCR testing. V5 said that staff should wear a surgical mask, faceshield, gloves and gown when entering a contact/droplet isolation room. V5 said that it should be documented in the nursing notes if a COVID test was performed.
On 9/13/23 at 12:48 PM, V5 said that in the evening of 9/12/23 (5 days after R100's documented symptoms) when he was working the floor, he tested R100 for COVID-19 and placed him on isolation.
The only COVID-19 testing that was provided as being done for R100 was a rapid test that was performed on 9/12/23.
2. On 9/11/23 at 10:25 AM, R121 was walking down the hallway and coughing. R121 sat in a chair near the nurse's station. Two other residents were sitting in chairs on each side of R121. The residents were not 6 feet apart and did not have masks on. The other two residents were cough.
On 9/12/23 at 9:00 AM, R121 was in his room. R121 said that he has been coughing and short of breath since Friday. R121 was not on isolation and R121 had a roommate.
R121's Nursing Notes dated 9/11/23 at 1:23 PM shows, Resident complaining about coughing. [Nurse Practitioner] made aware, per NP received new order chest x-ray, and mucinex 600 mg twice a day
R121's Electronic Medical Record from 9/8/23-9/12/23 does not document that the resident was placed on isolation or COVID-19 tested.
On 9/13/23 at 12:48 PM, V5 (Infection Control Nurse) said that in the evening of 9/12/23 when he was working the floor, he tested R121 for COVID-19 and placed him on isolation.
3. On 9/12/23 at 9:09 AM, R83 was heard from the hallway coughing. R83 said, I wish I could quit hacking. R83 was not on isolation and had a roommate present in her room. R83 said that she has had a cough and sore throat for about 3 days.
R83's Electronic Medical Record from 9/8/23 to 9/12/23 does not document that she has a cough or sore throat or that she was COVID-19 tested.
On 9/12/23 at 1:38 PM, V20 (Licensed Practical Nurse) said that she was not aware that R83 had a cough or sore throat.
On 9/13/23 at 12:48 PM, V5 (Infection Control Nurse) said that he is not aware that R83 has a cough or sore throat. V5 said that he is not sure how often the nurse's assess the resident for signs and symptoms of COVID-19 but he thinks it might be once a shift.
The facility's Managing of Residents with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact Policy dated 7/2023 shows, Residents Suspected to have COVID-19-Test symptomatic residents regardless of vaccination status .Resident placement: Single room with door closed if safe to do so .If limited single rooms are available or if numerous resident are simultaneously identified to have COVID-19 exposure or symptoms draw a privacy curtain between the beds, and wait for test results Isolate empirically using Transmission-Based Precautions until results of tests are known .Monitor resident at least daily screen for signs and symptoms of COVID-19 Staff must wear full PPE (N95 respiratory, gown, gloves, eye protection) when providing care The decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current COVID-19 infection for a resident with symptoms of COVID-19 can be made based on having negative results from one PCR test.
4. On 9/11/2023 at 10:48 AM, 12:22 PM, and 1:41 PM no isolation signs of any kind were observed outside of R10's room. No isolation cart or Personal Protective Equipment (PPE) was observed outside of R10's room either.
On 9/11/2023 at 12:36 PM, V5 Infection Control Preventionist (ICP) said R10 developed a cough on 9/9/2023. V5 said R10 was swabbed for COVID-19 and was placed on contract/droplet isolation. V5 said the testing used was a rapid test and no PCR tests were completed for any residents tested for COVID-19. V5 said R10 should have still been on isolation on 9/11/2023. V5 said staff members caring for residents with COVID-19 symptoms but negative test results should wear mask, gloves, gown, and face shield while caring for the resident. V5 said an isolation cart with PPE should be placed outside of the room for any resident on isolation.
R10's Order Summary Report dated 9/11/2023 shows an order for isolation contact and droplet precautions with a start date of 9/9/2023 and end date of 9/19/2023.
5. On 9/11/2023 at 9:40 AM, R115's room was observed to have an enhanced barrier precautions (EBP) sign on the door, but no isolation supply cart or PPE outside of the door.
On 9/11/2023 at 9:42 AM, R115 said he had a stuffed-up nose and was swabbed for COVID-19 last week but was never placed on the correct isolation. R115 said facility staff had not been wearing masks when coming into his room since he was swabbed. R115 said he had some medic training in the military and understands some level of infection control practices.
On 9/11/2023 at 12:24 PM, R115's room was observed to have an EBP sign but no other isolation sings and no isolation cart outside of the resident's room.
On 9/11/2023 at 12:30 PM, V24 Registered Nurse (RN) said she was assigned to R115's room. V24 said R115 should be on contact/droplet isolation for COVID-19 exposure or symptoms.
On 9/13/2023 at 12:36 PM, V5 said R115 was swabbed using a rapid test for COVID-19 on 9/7/2023 due to occasional coughing and complaints of body aches. V5 said R115 should have remained on isolation until 9/12/2023, pending three negative COVID-19 testing results.
R115's Physician Order's show an order for contact droplet isolation with a start date of 9/7/2023 and end date of 9/17/2023.
R115's Minimum Data Set (MDS) section C dated 8/18/2023 shows a BIMs score of 15, cognitively intact.
The facility provided COVID-19 testing plan policy states rapid antigen testing should be performed for staff and/or residents who develop symptoms consistent with COVID-19 (even mild symptoms), regardless of their vaccination status. Should an individual with symptoms consistent with COVID-19 have negative results from a rapid antigen test, they should remain excluded from work and/or isolated pending the results of confirmatory PCR testing.
The facility provided Management of Resident with Confirmed or Suspected COVID-19 Infection or Identified as a Close Contact policy states the decision to discontinue empiric Transmission-Based Precautions by excluding the diagnosis of current COVID-19 infection for a resident with symptoms of COVID-19 can be made based upon having negative results from one PCR test.

Based on observation, interview and record review the facility failed to ensure a resident was safely transferred using a gait belt for 1 of 31 residents (R100) reviewed for safety in the sample of 31.
The findings include:
On 9/11/23 at 9:30 AM, V17, Certified Nursing Assistant (CNA) assisted R100 to sit on the side of the bed. V17 stated, I know, you are weak and not feeling good today. V17 then assisted R100 to transfer to the wheelchair by holding onto the back of his pants and under his arm. R100 appeared very unsteady. V17 then assisted R100 back to bed by lifting him from under his arm to help him stand from the wheelchair.
On 9/13/23 at 9:13 AM, V6 (Physical Therapist) said that they did not see R100 on 9/11/23 because he was not feeling good. V6 said that if R100 is sick and weak, a gait belt should be used when helping him transfer.
The facility's Gait Belt/Transfer Belt Policy dated 9/2020 shows, To assist with a transfer or ambulation. A gait belt will be used with weight-bearing residents who require hands on assistance.

Based on observation, interview, and record review, the facility failed to ensure pureed rice was prepared and served in a smooth, palatable consistency for 4 of 14 (R105, R154, R68, and R64) residents reviewed for food palatability in the sample of 31.
The findings include:
The facility's Diet Type Report dated 9/11/23 shows R105, R68, R64, and R154 are all on a pureed diet.
During the initial kitchen tour on 9/11/23 at 9:21 AM, V13, Cook, said they are having chicken, broccoli and rice for the lunch meal.
On 9/11/23 at 10:58 AM, V13 said when making pureed foods he wants to make it to a smooth, pudding like consistency. V13 said he tastes the pureed foods to make sure they are very smooth.
On 9/11/23 at 12:53 PM, a sample tray of the pureed lunch meal was obtained and tasted by the survey team. The pureed rice had an unappetizing, chunky texture which required chewing.
The facility's Puree Prep Policy (revised 8/18) shows puree food will be palatable, attractive and prepared in a safe manner and will be puree to mashed potato or applesauce consistency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the resident dining area was safe and free from electrical hazards. This applies to 1 of 31 residents (R58) reviewed for safety hazards in the sample of 31.
The findings include:
On 9/11/23 at 12:45 PM, R58 was sitting in the dining room in her wheelchair. R58 had her back to the wall/window and her wheelchair was locked in place. R58's arms and legs are in constant motion (symptom of her diagnosis) and R58 constantly places her right hand in her mouth. On the wall behind R58 the plate covering the electrical outlet was broken and coming off of the wall. Two times R58 grabbed onto plate with her right hand and pulled at it, spinning it around with her wet fingers behind the plate. During the second time of holding onto the outlet V14 (MDS Coordinator) who was sitting at the table next to R58, saw what R58 was doing and removed her hand from the outlet cover.
On 9/12/23 at 8:28 AM, V15 (Maintenance) stated, The staff usually text me when they need something fixed. I come up every morning about 6:30 AM and talk to the night shift and day shift and see if there is anything they need. There are also sheets in the folders at the nurse's station they can fill out and leave for me. The only thing on the third floor today is a toilet in room [ROOM NUMBER]. Surveyor walked with V15 to the dining room and showed him the broken cover on the electrical outlet. R58 was again sitting in front of the outlet. V15 stated, I can go downstairs and grab a new one right now. V15 was asked if there was any danger in the outlet cover being broken and R58 playing with it. V15 stated, I'm sure if she stuck a fork in it or something she could get shocked.
On 9/12/23 at 8:35 AM, V15 asked V3 (Assistant Administrator) to stand by R58 while he went downstairs to get the new outlet cover. V3 stated that R58 has oral fixation and puts everything in her mouth. V3 stated that R58 grabs at everything around her and they have to be careful where they place her.
R58's Face Sheet shows she was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease with early onset and Unspecified Psychosis not due to substance or known psychological condition.
R58's Minimum Data Set Assessment of 6/14/23 shows that R58 has severe cognitive impairment.

Based on observation, interview, and record review the facility failed to treat residents in a dignified manner. This applies to 1 of 31 (R10) residents reviewed for dignity in the sample of 31.
The findings include:
On 9/11/2023 at 10:48 AM, two urinals were observed sitting by the window full of urine near R10's bed, unemptied.
On 9/11/2023 at 10:48 AM, R10 said the urinals had been there since the previous day. R10 said facility staff don't empty his urinals when they come by. R10 said he is sick of this and it happens all the time.
On 9/11/2023 at 12:22 PM and 1:41 PM, two urinals were observed still sitting by the window full of urine near R10's bed, unemptied.
On 9/13/2023 at 9:30 AM, V4 Director of Nursing (DON) said facility staff are responsible for helping residents who use urinals, including set up and emptying the urinals for the residents. V4 said facility staff should be rounding on residents at least every two hours and should be addressing residents care needs during those times, unless the resident requests sooner. V4 said R10 is alert and oriented.
R10's Minimum Data Set (MDS) section C dated 8/8/2023 lists R10's BIMS score as 13, cognitively intact.
R10's MDS section G shows the resident as needing supervision and set up help while using a urinal.
The facility provided Dignity policy dated 6/2023, states residents should be treated with dignity and respect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Activities of Daily Living (ADL) cares including showers and shaving were being completed for 4 of 31 residents (R123, R125, R52 and R35) reviewed for ADL's in the sample of 31.
The findings include:
1.) On 9/11/23 at 10:43 AM, R123 said his biggest complaint about the facility is the fact he is not getting showered regularly, and also has not been shaved in 2-3 weeks. He said he is supposed to receive showers on Tuesday and Friday evenings. R123 had scruffy facial hair and a partial beard growing. He said, When I ask about a shower or shaving I get told they are too busy or short staffed and cannot do it but look at me I have never had a beard.
R123's facility assessment completed on 7/3/23 shows his cognition is intact. R123's ADL care plan initiated on 9/13/22 shows he requires extensive staff assistance with his ADL's including grooming and showering.
The facility shower schedule reviewed on 9/12/23, shows R123 should receive showers on Tuesday and Friday evenings. The shower book was also reviewed by this surveyor on 9/12/23 and it had 1 shower sheet in it for R123 dated 7/18/23. On 9/13/23 the facility provided shower sheets for R123. Those sheets dated between 8/17/23 and 9/11/23 show he had a shower on 8/17/23 and again on 8/31/23. The sheets indicate he either refused a shower, or was given bed baths on 8/21, 8/24, 8/28, 9/4, 9/7 and 9/11.
On 9/12/23 at 1:34 PM, R123 was in his room visiting with V12 (R123's family member). V12 said she went out and bought R123 a electric razor and a hair trimmer in hopes that would help get someone to shave him and clip his hair. V12 said it is a big problem here, with R123 not being showered regularly. This surveyor asked R123 if he had in fact received a bed bath on Monday 9/11/23 (as the shower sheets indicated) and R123 said he did not receive a bed bath, and his shower days are Tuesdays and Fridays.
On 9/12/23 at 1:51 PM, V11 (Certified Nursing Assistant/CNA) said R123 does complain a lot about not getting showered on the evening shift. She said they cannot do all of the showers on day shift but she tries to help out and do extra when she can. R123 said she did in fact shave R123 but it has been 2-3 weeks since she did.
On 9/13/23 at 9:47 AM, V10 (Agency CNA) said residents can be shaved when they are showered but they also have shaving days where staff go around and shave residents.
2.) On 9/11/23 at 11:28 AM, V9 (R125's family member) was in the bathroom with R125 shaving him. V9 said there is a problem at the facility with showers and shaving. He said R125 is not getting showered or shaved regularly by the facility. V9 said he has mentioned it many times to staff when R125 does not receive his shower. V9 also said R125 is alert and with it and he knows if he had a shower or not. He said, today is supposed to be his (R125's) shower day but watch he won't end up getting one.
On 9/12/23 at 1:49 PM, both V9 and R125 said that R125 did not receive his shower on 9/11/23. V9 said I reminded several staff before I left yesterday (9/11/23) that he (R125) still needed his shower. V9 said the only reason R125's hair is not greasy is because he took him down for a hair cut and they washed it.
On 9/12/23 at 1:42 PM, V8 (CNA) said residents should be showered 2 times a week, and they document it is done on shower sheets that are then placed in the shower book and also in the computer in residents medical record. V8 was asked by the surveyor if R125 had received his shower on 9/11/23 and she confirmed he did not receive one due to time constraints.
The facility shower sheets in the shower book shows R125 is scheduled for showers on Monday and Thursdays on day shift. The facility provided shower sheets to the surveyors on 9/13/23 (that were not in the book on 9/12/23). Those shower sheets have documented and signed off that R125 not only received a shower on 9/11/23 but also on 9/14/23, 9/18/23, and 9/21/23. The sheets appear to be already filled out and signed for his upcoming showers.
R125's electronic medical record (EMR) task charting for showers show his last documented shower was 8/31/23.
3.) On 9/11/23 at 9:32 AM, R52 said he had a spinal cord injury and now requires a lift to transfer out of bed. He said when asks about getting a shower he is told that they have to use a lift to transfer him to the shower chair and don't have enough people to do that. R52 said he has been at the facility since February and has probably had 2-3 showers and 6 bed baths in total. He said he has refused a bed bath on one occasion due to them coming to his room very late in the evening. R52 said he is supposed to receive his showers on Tuesday and Friday evenings.
On 9/12/23 at 1:51 PM, V11 (CNA) said R52 does complain that he is not receiving his showers on the evening shift.
R52's 8/22/23 facility assessment show his cognition is intact and he requires extensive staff assistance with his ADL's including bathing and grooming.
The facility shower book shows R52 should receive his showers on Tuesday and Friday evenings. On 9/12/23 the shower book had no shower sheets for R52 inside. The facility provided shower sheets to the surveyors on 9/13/23 that had documented R52 received bed baths on 8/22/23, 8/25/23, and 9/5/23. Those sheets also document that R52 refused showers on 9/1/23 and 9/8/23 and the sheet for 9/12/23 is pre-signed but not indicated if he had a shower or not.
R52's (EMR) task charting for showers show his last documented shower was 9/9/23 and that shower documentation says he receives showers on Wednesdays and Saturdays. The dates in the computer and the documented bed baths/showers for R52 do not correspond with the sheets provided by the facility.
On 9/13/23 at 9:51 AM, R52 said he did not receive his scheduled shower on 9/12/23. He said he even reminded several staff it was his shower day but still didn't get one. R52 said he has not recently refused any showers or bed baths and he last received a bed bath 3 weeks ago.
R52's active care plan does not show any refusals of care documented.
4.) On 9/12/23 at 11:27 AM, R35 was in bed. Her hair appeared very messy and to have not been brushed in awhile. She had some dried food on her chin and gown. R35 said she has not been getting baths recently. She said when she asks about one the staff tell her the shower bed is broken.
R35's facility assessment dated [DATE] shows her cognition is intact and she requires extensive staff assistance with her ADL's including bathing and grooming.
The facility shower book shows that R35 should receive showers on Tuesday and Friday evenings. The shower book reviewed on 9/12/23 had 1 documented shower on 8/10/23 for R35. R35's EMR shower task charting shows 1 documented shower for R35 on 8/25/23. That charting has no documented refusals of showers. The facility provided shower sheets on 9/12/23 show R35 refused showers on 8/15/23, 8/18/23, 8/22/23, 8/29/23, 9/1/23 and 9/12/23. The sheets have documented that R35 received a bed bath on 8/18/23, 8/22/23, 9/5/23 and 9/8/23.
On 9/13/23 at 9:45 AM, R35 said, I have not refused a shower. I want a shower but they tell me the shower bed is broken. It has been a month since I had a shower.
R35's active care plan does not show any refusals of care documented.
The facility provided ADL policy dated 9/20 for Bath,Tub or Shower, and Shaving the Resident says the purpose is to bring comfort and cleanliness to the resident. The policies do not address time frames that showers should be given or the required documentation. The policy does list shaving should also be completed for the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure treatment orders were implemented for a resident with a fungal infection and failed to ensure a resident's eye was assessed and treatments ordered in a timely manner for 2 of 31 residents (R83 and R100) reviewed for quality of care in the sample of 31.
The findings include:
1. R83's Face Sheet shows that she was admitted to the facility on [DATE] with diagnoses of: cellulitis of buttock, local infection of the skin, dermatitis and non-pressure chronic ulcer of buttock.
R83's Infectious Disease Hospital Consult Note dated 8/16/23 shows, Assessment/Plan: Probable fungal dermatitis/diaper rash of the buttocks .Recommend: Topical nystatin (antifungal) to the buttocks at least 3 weeks.
R83's Medication List from the local hospital dated 8/16/23 shows nystatin topical to be applied three times a day.
R83's Wound Physician Notes dated 8/22/23 shows, Assessment and Plan: Diaper dermatitis-Apply miconazole (antifungal) 2% cream bid (twice a day) and prn (as needed) Pressure ulcer of right buttock, stage 3 miconazole 2% cream in periwound area . R83's Wound Physician Notes from 9/5/23 and 9/12/23 document the same as above.
On 9/11/23 at 12:32 PM, V22 (Wound Care Licensed Practical Nurse) performed a dressing change to R83's Stage 3 buttock pressure ulcer. R83's left and right buttock was bright red. V22 applied a dressing to the pressure wound and applied zinc ointment to R83's buttocks.
On 9/13/23 at 12:08 PM, V22 said that she just started the miconazole cream on 9/12/23. V22 said that she had just been using zinc in the past. V22 said that miconazole cream is used for fungal infections.
R83's August and September Medication Administration Record shows that she did not receive miconazole cream until 9/12/23.
2. On 9/11/23 at 9:30 AM, R100 was laying in bed. R100's left eye was red and had crusty discharge present. R100 stated, It hurts really bad and itches.
On 9/11/23 at 9:30 AM, V17 (Certified Nursing Assistant) said that R100's eye was red yesterday (9/10/23) but it looked worse today. V17 said that she had told the nurse about his eye.
On 9/12/23 at 1:23 PM, V17 said that both of R100's eyes were red and had drainage when she saw him in the morning. V17 said that she told the nurse after she cleaned them off.
On 09/12/23 at 1:50 PM, V19 (Registered Nurse) said that she saw R100's red eyes when she was doing medication pass in the morning and called the physician to notify them. V19 said that the physician ordered antibiotic ointment for his eyes. V19 said that if a resident is complaining of discomfort, drainage or their eyes are red, they should be assessed right away and the physician should be notified.
R100's Nursing Notes dated 9/12/23 at 11:01 AM shows, Resident both eyes have yellowish drainage, redness and verbalized discomfort in both eyes. Notified [Nurse Practitioner] order for ABT (antibiotic) ointment .
R100's Nursing Notes from 9/10/23 to 9/12/23 does not document anything about R100's eyes.

Based on interview and record review, the facility failed to ensure that a resident Physician or designee's progress notes are maintained in the facility records. This applies to 1 of 3 residents (R1) reviewed for Improper Nursing Care in the sample of 6.
The findings include:
R1's EMR (Electronic Medical Records) included diagnoses of chronic venous hypertension (idiopathic) with ulcer and inflammation of bilateral lower extremity, peripheral vascular disease, morbid (severe) obesity due to excess calories, cellulitis of left lower limb, non-pressure chronic ulcer of other part of right lower leg with fat layer exposed, non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, non-pressure chronic ulcer of right heel and midfoot with fat layer exposed, non-pressure chronic ulcer of left heel and midfoot with fat layer exposed. R1's Annual MDS (Minimum Data Set) dated 3/14/2023 showed that R1 was cognitively intact.
On 5/26/23 at 9:40 AM, R1 stated that the residents are supposed to have visits from the PCP (Primary Care Physician) and hasn't seen one for over a year. R1 stated that he is seen by the Infectious Disease NP (Nurse Practitioner) one-two times a month or more often if he is fighting an infection. R1 stated that his Palliative Care NP sees him weekly routinely. R1 remarked that his PCP V8 and her team communicate with the nurse, and we are taken out of the loop and are in the dark.
On 5/26/23 at 10:29 AM, V7 (Registered Nurse) stated that R1's PCP V8's practice has V9 NP and V10 (Physician Assistant) who come to see her patients. V7 added that V9 comes every Friday and sees patients that are on the list.
On 05/26/23 at 2:58 PM, V6 ADON (Assistant Director of Nursing) stated that the facility follows the policy for residents to be seen routinely by PCP and NP or PA. V6 added that the NP's that are with Infectious Disease or Palliative Care are not under V8's Practice.
Review of R1's EMR (on 05/26/23) for past six months did not show V8's or her support team's progress notes. Per request from facility V9's late entry (dated 05/26/23) progress notes and plan of care were obtained from V9 showing visits with R1 dated 12/05/22 and 05/05/22.
On 5/27/23 at 10:17 AM, V3 (Assistant Administrator) stated that she has reached out to V8's office to obtain records of her visits.
On 05/27/23 at 1:41 PM, V8's late entry (dated 5/27/23) progress notes and plan of care were obtained from V8 showing visits with R1 dated 1/5/23, 3/02/23 and 4/27/23.
Facility Policy and Procedure titled Medical Care Services included as follows:
Policy: Resident will receive medical care and services which meet their their individual needs and ensure adequate health care.
Procedures:
1. All residents shall be under the care of a Physician.
5. After the initial physician visit in SNF (Skilled Nursing Facility) a qualified Nurse Practitioner NP or PA may make every other required visit.
9. The attending physician or designee will be notified of all emergencies and changes in resident condition. The facility staff will obtain and record the physician's plan of care and treatment in the resident's record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents who suffered from abuse received services and interventions to promote psychosocial wellbeing. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 8.
The findings include:
The facility's final report to the State Agency dated May 5, 2023, shows, On 04/29/23 at approximately 6:00 PM, the nurse witnessed both resident's (R1 and R2) arguing and had physical contact .
On May 8, 2023, at 3:37 PM, R1 was in his wheelchair in the dining room. R1 had an eyepatch over his right eye. R1 said, [R2] punched me and hurt my eye.
On May 8, 2023, at 2:13 PM, R2 said, I have a problem with another resident, [R1]. He's over there in the dining room right now (R2 gestured towards the dining room across from where he was sitting). [R1] has yelled at me and called me an [expletive]. I had enough. I tried to talk to staff about it, but no one ever talked to me. [R1] and I got in an argument on Friday, I couldn't sleep all night because of it. The next day, [R1] was coming out of the bathroom and said, '[Expletive], you're going to jail.' So, I slapped him a few times. It hasn't gotten better since we changed rooms.
On May 8, 2023, at 1:59 PM, V10 (Social Services Director) said, The incident happened when [R1] was in the bathroom on the first floor and [R2] was trying to use the bathroom. We have told [R1] to use the bathroom on his floor. We have done behavioral contracts with [R1] and [R2]. We did a contract in March because there was a verbal incident. I have seen [R1] stick his middle finger up at [R2], and I have seen [R1] be verbally aggressive towards [R2]. We had to do a second behavioral contract since this was assault. The second contract is the same as the first contract, but with different consequences since it has gotten physical. The contracts are to monitor their behavior and make sure they are not engaging. Monitoring is the only thing we can do in this situation. [R1] doesn't come to [R2]'s floor usually, but he is up here now. I will have to talk to him about it.
On May 8, 2023, at 1:01 PM, R2 was self-propelling in his wheelchair in the basement of the facility. R2 was unaccompanied by staff.
On May 8, 2023, at 1:54 PM, R1 was propelling in his motorized wheelchair on the second floor (R1's floor), not escorted by staff.
On May 10, 2023, at 10:47 AM, V10 said, Since the physical altercation the new behavior contract was put in place on May 1, 2023. Monitoring was put in place at that time and making sure a staff member is with [R1] or [R2] if they are leaving their floor. These are the only interventions we have put in place.
On May 9, 2023, at 1:08 PM, V9 (RN) said, A couple of days ago, I was leaving work and [R2] was bringing a remote control to [R1]'s floor and [R1] started yelling at [R2]. [R1] was yelling 'You can't be down here, we have contracts.' At that time, I was unaware [R2] was not supposed to go downstairs. [R2] doesn't ask staff for help when he wants to go downstairs, we just have to watch for him and then send someone with him. [R2] likes to go downstairs and color.
On May 9, 2023, at 2:11 PM, V13 (R2's Psychiatric Nurse Practitioner) said [R1] is bullying [R2] and swearing at [R2] without provocation and [R2] gets agitated. [R2] told me yesterday, that [R1] came to [R2]'s floor and was bullying [R2]. I think [R1] is verbally aggressive and bullying [R2] and that is provoking [R2]. I am not involved in [R1]'s care, I have never been consulted to see him.
On May 9, 2023, at 12:33 PM, V8 (LCSW/Licensed Clinical Social Worker) said, I provide psychotherapy services to the residents in this facility. The facility will provide me with a list of who needs to seen. There does not need to be a physician order for me to see a resident, anyone can refer a resident to me. Meeting with residents about physical and verbal aggression is something I can be involved in. I have no idea who [R1] or [R2] are, I have not been asked to see either of those residents. I am able to see more residents in this facility.
On May 9, 2023, at 3:18 PM, V11 (Physician) said he is R1 and R2's physician. V11 continues to say no one at the facility has spoken to V11 about additional services for either resident.
R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including: chronic obstructive pulmonary disease, Crohn's disease, heart failure, dementia, and anxiety.
R1's MDS (Minimum Data Set) dated April 12, 2023, shows R1 has moderate cognitive impairment. The MDS continues to show R1 requires limited assistance from facility staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and walking in room.
R1's abuse care plan revised on May 3, 2023, shows, [R1] is at risk for abuse related to: has a history of dementia, allegation that he was struck by another resident.
As of May 10, 2023, at 10:00 AM, The facility also does not have documentation to show interventions have been put in place to address R1's psychosocial needs or coping with physical abuse from other residents since the incident with R2 on April 29, 2023.
As of May 10, 2023, at 10:00 AM, the facility does not have documentation to show interventions have been put in place to address R1's verbal aggression since the incident with R2 on April 29, 2023.
As of May 10, 2023, at 10:00 AM, the facility does not have documentation to show R1 has been received psychiatric services since the incident with R2 on April 29, 2023.
R2's EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including: chronic obstructive pulmonary disease, heart failure, chronic kidney disease, depression, and dementia.
R2's MDS dated [DATE], shows R2 is cognitively intact. The MDS continues to show R2 requires supervision of facility staff for locomotion on and off the unit, toilet use, and eating.
R2's abuse care plan revised on February 22, 2023, shows, [R2] is at risk for abuse related to: diagnosis of dementia, major depression, history of yelling at staff, making threatening statements and history of verbal abuse from another resident. As of May 10, 2023, at 10:00 AM, R2's abuse care plan does not show additional interventions since the incident on April 29, 2023.
As of May 10, 2023, at 10:00 AM, the facility did not have documentation to show R2 has a care plan to address R2's physical aggression. The facility also does not have documentation to show interventions have been put in place to address R2's psychosocial needs or coping with verbal abuse from other residents since the incident with R1 on April 29, 2023.
As of May 10, 2023, at 10:00 AM, the facility does not have documentation to show R2 has received additional psychiatric services since the incident with R1 on April 29, 2023.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from physical and verbal abuse. This failure resulted in R1 experiencing a corneal abrasion following physical abuse by R2. This applies to 2 of 3 residents (R1 and R2) reviewed for abuse in the sample of 8.
The findings include:
1. On May 8, 2023, at 3:37 PM, R1 was in his wheelchair in the dining room. R1 had an eyepatch over his right eye. R1 said, [R2] punched me and hurt my eye.
R1's EMR (Electronic Medical Record) shows R1 was admitted to the facility on [DATE], with multiple diagnoses including: chronic obstructive pulmonary disease, Crohn's disease, heart failure, dementia, and anxiety.
R1's MDS (Minimum Data Set) dated April 12, 2023, shows R1 has moderate cognitive impairment. The MDS continues to show R1 requires limited assistance from facility staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and walking in room.
R1's abuse care plan revised on May 12, 2022, shows, [R1] is at risk for abuse related to: has a history of dementia.
The facility's final report to the State Agency dated May 5, 2023, shows, On 04/29/23 at approximately 6:00 PM, the nurse witnessed both resident's (R1 and R2) arguing and had physical contact .
On April 30, 2023, at 9:58 AM, V12 (emergency room Physician) documented, Presenting status post being physically assaulted by another member of his nursing facility. Patient states that a gentleman came up and punched him in the face breaking his glasses yesterday, says he was also struck several times in the right shoulder. Denies any other injuries during the assault, denies fall, denies head strike loss of consciousness other than where he was punched. Primary reason for presenting today is that he has some mild pain in the right eye and says that his vision is slightly blurry. Says he had difficulty sleeping last night because the pain. The documentation continues to show R1 was diagnosed with a corneal abrasion on his right eye in the Emergency Room.
On May 9, 2023, at 2:25 PM, V7 (RN/Registered Nurse) said, I was the nurse on April 29, 2023. I was in the dining room and I heard a commotion by the washroom, and I went over there. [R1] was in the doorway in the washroom, and the scene that I saw was [R2] hitting [R1]. [R1] was covering his face like a boxer and waving his head side to side. I saw [R2] hitting [R1]'s arms. [R2] was making contact with [R1]. It was really scary.
On May 8, 2023, at 2:13 PM, R2 said, I have a problem with another resident, [R1]. He has yelled at me and called me an [expletive]. I had enough. I tried to talk to staff about it, but no one ever talked to me. [R1] and I got in an argument on Friday, I couldn't sleep all night because of it. The next day, [R1] was coming out of the bathroom and said, '[Expletive], you're going to jail.' So, I slapped him a few times. It hasn't gotten better since we changed rooms.
On May 9, 2023, at 3:49 PM, V2 (DON/Director of Nursing) said physical abuse was substantiated for the incident on April 29, 2023.
On May 9, 2023, at 3:18 PM, V11 (Physician) said R1's corneal abrasion happened due to the physical altercation when R2 hit R1. V11 continues to say his expectation is residents should be free from abuse.
2. R2's EMR shows R2 was admitted to the facility on [DATE] with multiple diagnoses including: chronic obstructive pulmonary disease, heart failure, chronic kidney disease, depression, and dementia.
R2's MDS dated [DATE], shows R2 is cognitively intact. The MDS continues to show R2 requires supervision of facility staff for locomotion on and off the unit, toilet use, and eating.
R2's abuse care plan revised on February 22, 2023, shows, [R2] is at risk for abuse related to: diagnosis of dementia, major depression, history of yelling at staff, making threatening statements and history of verbal abuse from another resident.
On May 9, 2023, at 3:49 PM, V2 (DON/Director of Nursing) said, [R1] said, '[expletive] you, you are going to jail,' to [R2]. [R2] went to slap [R1] and [R1] covered his face. Verbal abuse was substantiated in this incident. There is not a separate reportable for [R1]'s verbal abuse to [R2].
On May 8, 2023, at 2:13 PM, R2 said, I have a problem with another resident, [R1]. He has yelled at me and called me an [expletive]. I had enough. I tried to talk to staff about it, but no one ever talked to me. [R1] and I got in an argument on Friday, I couldn't sleep all night because of it. The next day, [R1] was coming out of the bathroom and said, '[Expletive], you're going to jail.' So, I slapped him a few times. It hasn't gotten better since we changed rooms.
On May 9, 2023, at 2:11 PM, V13 (Psychiatric Nurse Practitioner) said, [R1] is bullying [R2] and swearing at [R2] without provocation and [R2] gets agitated. [R2] told me yesterday, that [R1] came to [R2]'s floor and was bullying [R2]. I think [R1] is verbally aggressive and bullying [R2] and that is provoking [R2].
On May 8, 2023, at 1:59 PM, V10 (Social Services Director) said, I have seen [R1] stick his middle finger up at [R2], and I have seen [R1] be verbally aggressive towards [R2].
The facility's policy titled, Abuse Policy, dated 09/20, shows, Policy: This facility affirms the right of our residents to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility will report reasonable suspicion of a crime. This facility therefore prohibits mistreatment, neglect or abuse of its residents and has attempted to establish a resident sensitive and resident secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of mistreatment, neglect or abuse of our residents. This will be done by: . 3. Establishing an environment that promotes resident sensitivity, resident security and prevention of mistreatment; 4. Identifying occurrences and patterns of potential mistreatment; 5. Immediately protecting residents involved in identifying reports of possible abuse; 6. Implementing systems to investigate all reports and allegations of mistreatment promptly and aggressively, and making the necessary changes to prevent future occurrences; 7. Filing accurate and timely investigative reports; This facility is committed to protecting our residents from abuse by anyone including, but not limited to, facility staff, other residents, consultants, volunteers, and staff from other agencies providing services to the individual, family members or legal guardians, friends, or any other individuals who have been convicted of abusing, neglecting, or mistreating individuals. Definitions: . Abuse means any physical or mental injury or sexual assault inflicted upon a resident other than by accidental means in a facility. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Willful means the individual acted deliberately, not that the individual must have intended the injury or harm . Physical abuse includes hitting, slapping, pinching, kicking and controlling behavior through corporal punishment . Verbal abuse is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or families, or within their hearing distance, regardless of their age, ability to comprehend or disability .