Alpine Fireside Health Center

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident's pain medication was administered for pain control. This applies to 1 of 5 residents (R1) reviewed for pain in the sample of 5. The findings include: R1's face sheet shows she was re-admitted to the facility on [DATE] following right femur fracture repair. R1's diagnosis includes peripheral vascular disease, Alzheimer's disease late onset, dementia unspecified, falls, diabetes, and osteoarthritis. R1's Physician Orders dated December 2025 shows orders including oxycodone (opioid) 5mg (milligrams) every 4 hours as needed for moderate or severe pain. R1's nurses notes dated 12/27/25 at 1:38 PM documents behaviors yelling/screaming. Pain severe pain interventions include scheduled pain medication administrated and as needed medication administration. R1's Medication Administration Record (M.A.R.) dated December 2025 shows there was no pain medication administered at 1:38 PM for R1's pain. R1's M.A.R. shows acetaminophen 325 mg was given at 3:34 PM. On 3/31/26 at 12:27 PM, V4 (Registered Nurse) said R1 was confused, she could not communicate if she was having pain it was more through her facial grimacing and behaviors. R1 was getting scheduled acetaminophen for pain and had orders for oxycodone as needed. If we are waiting for pain medication to be delivered from the pharmacy we can pull it from the emergency supply if needed. On 3/31/26 at 12:09 PM, V2 (Director of Nursing-DON) said R1 was re-admitted to the facility following a right femur fracture with surgical repair. We received discharge instructions from the hospital with the narcotic scripts. Sometimes the e-scripts are faxed to our pharmacy. She was not aware of R1 having pain concerns after her re-admission. If the narcotic is not available, nursing can pull the medication from the emergency supply box. Oxycodone was available in the emergency supply box. At 1:53 PM, V2 (DON) said R1 arrived to the facility on [DATE] at 10:27 AM. The nurse's note at 1:38 PM shows she was having severe pain. V2 confirmed R1 did not receive pain medication at that time. V2 said R1 could not communicate if she was having pain. R1 was more non-verbal showing pain with behaviors. Tylenol is not going to cut it for pain control for a resident following hip surgery. V2 said nursing should have pulled the narcotic pain medication from the emergency supply and confirmed the order was to give oxycodone 5mg for moderate to severe pain and she is not sure why nursing did not administer the narcotic. R1's Controlled Substance Record for Oxycodone 5 mg shows it was delivered to the facility on [DATE] at 10:00 PM. The sheet shows R1 received the first dose on 12/28/25 at 1:00 AM. The facility's Pain Management Policy reviewed 2025 states, the facility will ensure pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person centered- care plan and the residents goals and preferences. '

Based on observation, interview and record review the facility failed to ensure a resident with the diagnosis of dementia and known aggressive behaviors was cared for in a manner to prevent injury. This applies to 1 of 3 residents (R1) reviewed for dementia in the sample of 8. The findings include:R1's electronic medical records list his diagnoses to include: vascular dementia, major depressive disorder, cerebrovascular disease, chronic kidney disease, chronic obstructive pulmonary disease and benign prostatic hypertension. On 1/20/26 at 10:15 AM, R1 was sitting up in a reclining wheelchair in his room. He had a yellow, green and purple bruise under his right eye. A small red spot on the upper left side of his lip with some faint bruising to his chin. The spot appeared as if it was scabbed over and the scab recently fell off. R1 was very confused and incoherent. V3 R1's wife was in the room with R1. She stated, R1 got the bruising about a week prior. She had visited him on a Friday evening (1/9/26) and the facility called on 1/11/26 saying they found R1 with bruising to his right eye and a swollen lip. The facility was not sure how R1 received the injuries. The facility's reported incident (no date) for R1 shows, Incident Category: Bruise of unknown origin. Incident description: On the morning of 1/11/2026 staff reported that they identified bruising on Resident's face. Resident is unable to be interviewed related to impaired cognitive, memory and communication impairment. Final Description: On the morning of 01/11/2026 staff reported bruise of unknown origin. Nursing team reported that resident has bruising to face, hand and buttock. Resident has a diagnosis of Dementia, severe, end stage. Related to cognitive impairment, resident is unable to communicate effectively and often does not fully understand commands. Resident gave a nonsensical response when interview was attempted by SSD (social service designee). 2nd shift Nurse reported that resident was combative during evening care and that 2 staff were required to assist with his care. Nurse reported that she observed that resident did not have any bruising during her shift. 3rd shift CNA (V9 CNA-Certified Nursing Assistant) interviewed. She stated that resident was very combative during care. She stated that is was especially difficult to remove his shirt that was soiled. She reported that his arm kept getting stuck in his shirt. She stated that his arms were moving all over. She stated that she informed the nurse. She stated that when she completed a later bed check on resident, she did not observe any bruising; however, resident does lay in bed with covers over face. On 1/20/26 at 2:16 PM, V8 CNA stated, she worked a double on Saturday 1/10/26 (day and evening shift). She came back on 1/11/26 for day shift. She put R1 to bed on 1/10/26 and he did not have any bruising to his face. When she came back on Sunday (1/11/26) V9 CNA reported to her that when she was changing him overnight he some how bit his lip. She advised V9 CNA to not change R1 by herself because of his behaviors. V9 CNA did not report any bruising to R1's face to V8 CNA. When V8 CNA went to get R1 up she noticed he had a black eye and cut on his lip. She reported the injuries to the nurse. She continued to state, R1 can be combative, and she always has another person with her when she is caring for him which is why she told V9 CNA to get help when R1 is being combative. On 1/20/26 at 1:33 PM, V9 CNA stated, she worked with R1 on 3rd shift on 1/10/26. When she checked on R1 he had clothes on and they were soiled/wet. She had to change him out of his clothes. He was combative as he usually is. She stated, they were short a CNA so she did not stop and get help. She did report to the nurse that he was combative. She did not see any bruising on his face. She also stated, the facility suspended her following the incident. She has not returned to work since. On 1/20/26 at 1:23 PM, V12 Registered Nurse stated, she worked with R1 on 3rd shift on 1/10/26. V9 CNA reported to her that R1 was combative but nothing else. She did not give R1 any medication to help with his behaviors. On 1/20/26 at 10:15 AM, V4 Hospice Nurse Case Manager stated, R1 has been getting more combative with cares that last couple of weeks. On Friday 1/9/26 they met with R1's family and had a care plan meeting. They discussed his behaviors and some tools to put in place to help. He has medication ordered that could be given to help and some other non-pharmacological interventions. She was aware of the bruising and stated, R1 can be aggressive when you are trying to care for him. She felt the staff needed more training on how to care for R1 with his dementia. They could give him medications or even re-approach later. R1's progress notes dated 1/9/26 shows, On 01/09/2026, this writer, SSD and DON (Director of Nursing), CNA supervisor, and Activity Director met with spouse/POA (power of attorney) and daughter, and hospice nurse case manager for a care plan meeting. Resident was unable to participate in meeting, related to cognitive impairment. Resident is also unable to communicate effectively and, although occasionally can put sentences together, most often speaks nonsensically. Reviewed resident's overall decline in cognition, ADLs (activities of daily living), and increase in agitation/behaviors, likely due to progressing Dementia. Hospice Nurse Case Manager confirmed that she has also observed these changes. Discussed strategies for staff approaches regarding care and comfort. Made medication changes. Family reported that they may bring in a recliner for his comfort. Staff are aware of non-pharm approach of Rubik's cube and resident pulling covers over his face for self-soothing. R1's progress notes dated 1/11/26 shows, early in morning I was told by the CNA, the resident has bruising bellow the right eye and lips swell. CNA stated she worked last night and she did not left him like that during my report the night shift nurse did not mention anything about this incident. She only said he was doing fine. (sic (statement is correct). R1's January medication administration record shows, he has an order for haloperidol (anti-anxiety) to be given every 6 hours as needed. The medication was ordered on 1/8/26 and has not been used since ordered. R1's care plan dated 1/9/26 shows, Problems/Strengths: Episodes of physical behaviors towards others as evidenced by resident gets agitated during the care, and becomes physical aggressive towards staff. Interventions: administer medications and monitor for side effects. When resident is showing physical behaviors attempt to refocus to positive behaviors. If appropriate, stop care when resident is agitated and try again later. The facility's dementia training policy dated 2026 shows, Policy Statement: Dementia poses unique challenges in long-term settings, necessitating specialized approaches to ensure residents receive the best possible support. Understanding the complexities of dementia and implementing person-centered care strategies are crucial for enhancing quality of life and well-being for those with dementia. Training new staff and ongoing training is essential to ensure the specialized care those with dementia need.

Based on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation of a resident's monies. This applies to 1 of 3 residents (R2) reviewed for misappropriation in the sample of 8. The findings include:On 1/20/26 at 11:55 AM, R2 stated, she had money stolen from the facility. The facility's reported incident report (no date) shows, R2 had money missing from her room. The same report continues to show, Several staff of varying departments and across all shifts were interviewed. No reports of questionable behavior reported. Cameras reviewed between the time Resident's son reportedly provided the $90.00 and the time of initial report. All staff that entered the room were assigned to the Resident. The times that each staff entered the room are appropriate for each staff's assigned responsibility. Staff that entered the room were interviewed, no concerns were identified. On 1/21/26 facility surveillance video footage from 1/6/26 starting at approximately 4:30 PM to 1/8/26 at approximately 8:30 AM was viewed with V16 Dietary Manager/IT and V15 Certified Nursing Assistant (CNA) Supervisor. The surveillance video footage was of R2's hallway. R2's room was visible and anyone who entered or exited the room could be seen in the video footage. During the timeframe viewed, 4 staff members (V17, V18, V19 and V20 all Certified Nursing Assistants (CNAs)) were seen entering R2's room when R2 was NOT in the room. On 1/21/26 at 11:21 AM, V7 Social Service Designee stated, she was the one who interviewed staff after R2 reported her money was missing. V15 CNA supervisor watched the surveillance video footage and did not tell her she saw anyone in the room when they shouldn't have been. She interviewed staff but only asked them a few questions. She was never told that V17, V18, V19 and V20 all CNAs were in R2's room when R2 was not so she did not ask any specific questions about why they were in her room during the timeframe R2's money went missing. On 1/21/26 at 11:21 AM, V15 CNA Supervisor stated, she watched the video footage but could not remember what she saw and needed to see the video again. This surveyor and V15 CNA supervisor watched some of the video footage again and V15 stated, she was just watching who was going in and out of the rooms but not when or if R2 was in the room or not. She also stated, everyone that went in the room was assigned to R2 so she didn't think anymore of it. She understood, they could have done a better investigation after viewing the video footage again. V17, V18 and V20 all CNAs typewritten interview forms show the following questions were asked: Have you heard or seen any inappropriate or questionable interactions between any of your residents and staff? Have you noticed that any change in the mood or demeanor of the residents you care for recently? Have you noticed that any of your co-workers are exhibiting signs of stress and or burnout? They all answered No to all three questions. The facility did not provide a typewritten statement for V19 CNA. None of the forms show, they were asked specifically why they were in R2's room when she was not and what they were doing. The facility's investigating incident of theft and/or misappropriation of resident property policy (no date) shows, Policy Statement: All reports of theft or misappropriation of resident property shall be promptly and thoroughly investigated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident was free from misappropriation of monies. This applies to 1 of 3 residents (R2) reviewed for misappropriation in the sample of 8. The findings include:On 1/20/26 at 11:55 AM, R2 stated, she wanted to get her hair done but wasn't sure what day the hairdresser would be in. She asked her son to bring her some money so she could pay for her hair to be done. He brought the money in and put it in her purse in the bottom drawer of a dresser in her room. A day or two later, she went to get the money out of her purse and found the money was gone. She told her son the money was gone and asked him to bring her more so she could get her hair done. On 1/20/26 at 1:02 PM, V14 R2's son stated, his mom had asked him to bring $90.00 on Tuesday (1/6/26) because she wanted to get a hair cut and perm. Her hair appointment was scheduled for Thursday morning (1/8/26). He brought the money to her that evening and put it in her purse in the bottom drawer of a dresser in her room. Her purse also had a $10.00 and couple of $5.00 bills in there. On Thursday his mom went to get the money to go to the hairdresser when she found all the money was gone. His mom texted him and told him the money was gone and she needed more money. He came to the facility with more money and they reported it to the staff. He guessed there was another $15-20.00 in there so about a total loss of $120.00. He is the one who put the money in the purse so he knows the money was in her purse in her room at the facility. The facility's reported incident (no date) for R2 shows, Incident category: Financial. Incident Description: Resident reported that she is missing approximately $110.00. She stated that her son recently brought her $90.00. Final description: On 1/08/2026 Resident (R2) reported that she was missing approximately $110.00. Resident's son/POAH (power of attorney healthcare), V14 was present during interview. Resident reported that her son brought $90.00 to her on 1/06/2026 which she put in her purse along with other monies, that she believed was approximately another $20.00. Resident stated that in the morning of 1/08/2026 she was looking in her purse and the money was missing. Resident stated that she kept the money in her purse, in bottom drawer of the dresser. Resident's room searched. Monies not located.On 1/20/26 at 2:24 PM, V7 Social Service Designee stated, R2 reported she had money and it went missing. They were not able to find the money or replace the money.R2's electronic medical record showed, her Minimum Data Set, dated [DATE] that she is cognitively intact. The facility's investigating incident of theft and/or misappropriation of resident property policy (no date) shows, Policy Interpretation and Implementation: .2. Misappropriation of resident property is defined as the patterned or deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure fall prevention interventions were in place for a resident with a history of falls for 1 of 3 residents (R1) reviewed for falls in the sample of 6. This failure resulted in R1 falling and sustaining a right hip fracture and right knee fracture.The findings include:R1's Progress Note dated 12/23/25 shows Approximately 1:30 AM, R1 alarm was sounding and Certified Nursing Assistant (CNA) observed R1 on floor, lying on right side. R1 complained of pain to right hip during range of motion. R1 is alert and oriented to self, has a history of falls, and has diagnosis Alzheimer's ad Dementia. R1 has poor safety awareness, has impaired decision making and requires frequent redirection from staff.R1's Emergency Department Provider Note dated 12/23/25 shows R1 presents to the Emergency Department following a fall at the skilled nursing facility. The patient has sustained a right intertrochanteric (hip) fracture. She also sustained a right patellar (knee) fracture. Patient will need admission to hospital for further management. Care Timeline: 12/23/25 admitted from Emergency Department, 12/24/25 Surgery with Gamma Nail for Right Hip Fracture, 12/27/25 Discharge.On 12/31/25 at 8:55 AM, R1 was in bed sleeping.On 12/31/25 at 8:58 AM, V3 (Registered Nurse/RN) said R1 had a rough night, had been very anxious, and kept touching her right hip surgery site. V3 said R1 got a pain pill at 3:30 AM, so she was letting her rest.On 12/31/25 at 9:05 AM, V6 (R1's Daughter/Power of Attorney) said R1 had hip surgery on 12/24/25 and came back to the facility on [DATE]. V6 said R1 had been screaming, pulling at her surgical dressing and seemed like she couldn't get comfortable for the first 48 hours at the facility. V6 said they increase R1's pain medications and R1 seems to be resting better.On 12/31/25 at 10:43 AM, V8 (CNA) said on 12/23/25, R1 had been up and busy all night and was sitting up at the nurse's station with V10 (Licensed Practical Nurse/LPN). V8 said she was sitting at table at the beginning of hall 1, around the corner from the hall 2 nurse's station. V8 said V10 got up and went out the front door to go on break. V8 said within minutes she heard screaming, and she went to the nurse's station where R1 was on the floor on her right side. V8 said she was close by at a table at the end of hall 1, but she couldn't see R1 get up or how she fell.On 12/31/25 at 11:05 AM, V9 (CNA) said the night of R1's fall, she was coming out of the restroom by the nurse's station and heard an alarm going off and screaming. V9 said V8 was coming around the corner at the same time from hall 1. V9 said R1 was on the floor by the nurse's station. V9 said the nurse was not at the station.On 12/31/25 at 11:13 AM, V10 (LPN) said on 12/23/25, R1 had been at the nurse's station with her due to R1's behaviors (not sleeping, trying to get out of bed). V10 said she left the nurse's station to go on break. V10 said she left R1 at the nurse's station by herself and told V8 (CNA) who was around the corner from the nurse's station, that she was going on break. V10 said she left the building out the front door and when she came back in, an alarm was sounding, and R1 was on the floor at the nurse's station. On 12/31/25 at 11:19 AM, V2 (Director of Nursing) said R1 is alert to self and to her daughter. V2 said R1 doesn't understand what is going on and has behaviors of getting anxious and trying to stand up. V2 said R1 was on 1:1 care before this fall most of the time due to her anxiousness. V2 said per her care plan interventions, R1 is to have 1:1 care if she is anxious and trying to stand up. V2 said staff will keep R1 at the nurse's station to keep an eye on her but she shouldn't be left alone at the nurse's station if she is having these behaviors and is on 1:1.R1's Progress Note dated 12/22/25 at 11:01 PM, shows Entered during treatment pass of Monitor for behavior related to psychotropic medications (key 1-wandering, key 2-verbally abusive, key 3- socially inappropriate, key 4- paranoia, key 5- delusions, key 6-physically abusive, key 7- disruptive, key 8-pacing, key 9-crying, key 10-yelling/screaming, key 11-hallucinations, key 12- striking out, key 13-throwing things, key 14-self-inflicting injury, key 15-feeling down, key 16-not eating adequately, key 17-change in interest or activity, key 18-sleeping problems, key 19- felling angry/anxious, key 20-feeling restlessness/anxious. The results charted were 7-disruptive, 9-crying, 10-yelling/screaming, 18-sleeping problems. 19- feeling angry/anxious, 20-feeling restlessness/anxious.R1's Progress Note dated 12/23/25 at 4:44 AM, shows Entered during treatment pass of Monitor if resident is sleeping at night. (Key 1 - awake most of the night, Key 2- Awake few times at night, Key 3-slept good at 6:00 AM). Result -1 Awake all shift.R1's Care Plan dated 12/12/25 shows Resident behavior as exhibited by not staying in chair, removing her alarms and needing to be 1:1 by staff throughout the day due to increased anxiety/behavior such as restlessness and yelling.R1's Fall Risk assessment dated [DATE] shows R1 is a high risk/potential for falls based on resident gait or balance abnormal either with or without a device, resident is on medications that could impair balance, resident has a disease or condition that impacts ambulation, and resident has cognitive impairments/poor decision making.R1's Minimum Data Set, dated [DATE] shows R1 is cognitively impaired, has behaviors, and has history of falls.On 1/5/26 at 8:02 AM, V11 (Nurse Practitioner) said R1 has dementia, is alert to self only, unable to follow commands and has behaviors of restlessness and agitation. V11 said if R1 is having behaviors, R1 should have 1:1 care according to her care plan. The facility's undated Fall Policy shows On admission and re-admission, a Fall Risk Assessment will be completed. Interventions will then be implemented for those residents assessed at risk for falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure bed hold notices were provided for 2 residents (R1, R38) and failed to notify the ombudsman of resident transfers and discharges for 3 of 3 residents (R1, R38, R40) reviewed for discharge requirements in the sample of 12. The findings include: R38's face sheet and transfer packet shows he was transferred from the facility to the hospital on [DATE]. R38 did not return to the facility he was discharged to another placement. There is no bed hold or documentation in his electronic medical record (EMR) that one was provided on transfer or during hospitalization to R38 or to his representative. There is no documentation in the EMR that V14 (Ombudsman) was notified of his transfer or discharge. R40's face sheet and discharge summary shows he was a planned discharge from the facility on [DATE]. There is no documentation showing V14 was notified of his discharge. R1's facesheet and transfer packet shows she was transferred from the facility to the hospital on [DATE]. There is no documentation that a bed hold was provided to R1 or to her representative during or after the transfer, and no documentation that V14 was notified of R1's transfer. On [DATE] at 8:22 AM, V14 said facilities should be notifying the ombudsman program with resident discharges and this facility is one that has not be doing so. On [DATE] at 11:58 AM, V6 (Social Services) said she has not been notifying the Ombudsman office of resident transfers or discharges because she was not aware she was suppose to do so. V6 said V5 (admission Liason) is the person who speaks with the hospital after a resident is transferred so she is not sure if she provides any additional documentation or bed hold notices after they are transferred. V6 confirmed that R1 had been transferred to the hospital and did not return she later expired in the hospital, R38 was transferred from the hospital to another placement with his family and R40 was a planned discharge from the facility. On [DATE] at 12:07 PM, V2 (Director Of Nursing) said nursing does not send out bed hold notices on transfer and they also do not notify the Ombudsman of any discharges or transfers. V2 said she was unaware if anyone else in the facility, if V5 does or not. On [DATE] at 12:13 PM, V5 said she is not directly involved at the time of a resident transfer. V5 said she does follow up calls once a resident is in the hospital. V5 confirmed that no additional bed hold is sent because the residents receive a copy in their admission contract. V5 also said she do not send anything to V14. On [DATE] at 2:48 PM, V1 (Administrator) said bed holds are given to residents on admit to the facility. V1 also said she was unaware that the notices should be sent to the Ombudsman for all transfers and discharges and there is no facility policy for Ombudsman notification. The facility provided and not dated Bed Hold policy explains what the bed hold policy is, but does not address when an actual copy of the bed hold should be provided to a resident or their representative. The facility was unable to provide a policy on Ombudsman notifications.

**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) care was provided timely for a resident that requires assistance for one of 12 residents (R32) reviewed for ADL care in the sample of 12.The findings include:R32's Record of admission shows she was admitted to the facility on [DATE].R32's Physician Orders show she was admitted to the facility with diagnoses including anorexia, polyarthritis, excoriation disorder, difficulty walking, and paranoid schizophrenia.On December 8, 2025, at 11:20 AM, V9 Certified Nursing Assistant (CNA) stood R32 up via the mechanical stand lift. There was a large wet circle to the back of R32's pants. V9 placed R32 onto the toilet and removed R32's incontinence brief. R32 had a thick disposable incontinence pad plus an incontinence brief on. Both the pad and the brief were saturated with urine. There was a strong urine smell. V9 said that R32 has an incontinence pad and incontinence brief on because R32 is a heavy wetter. V9 said R32 has been up in her wheelchair since about 8:00 AM.R32's Care plan effective September 20, 2025, shows she is at risk for skin breakdown related to bowel and bladder incontinence. Make sure resident is clean and dry, changed as needed.On December 9, 2025, at 11:29 AM, V12 CNA said incontinence care should be done at least every two hours and as needed. V12 said residents should only have on one incontinence brief on at a time. V12 said if a resident is a heavy wetter, then they should be checked and changed more often.The facility's Activities of Daily Living (ADLs) policy not dated shows, A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for a resident with a pressure injury for one of two residents (R3) reviewed for pressure injuries in the sample of 12.The findings include:R3's Record of admission shows she was admitted to the facility on [DATE]. R3's Diagnoses Report shows she was admitted with diagnoses including sepsis, urinary tract infection, dementia, and pressure injury of sacral region.R3's Potential for skin breakdown assessment dated [DATE], shows she is a high risk for pressure injuries. R3 has an air mattress.R3's Physician Orders dated December 1, 2025-December 31, 2025, shows orders for waffle boots while in bed.R3's Care plan dated December 9, 2025, shows, Encourage resident to float heels while in bed and air mattress in bed.R3's Weekly Wound Assessment and Summary dated December 5, 2025, shows she has two stage 4 pressure injuries to her sacrum. These assessments show that R3 uses a low air loss mattress in bed. On December 8, 2025, at 1:03 PM, V9 and V10 Certified Nursing Assistants (CNAs) used a mechanical lift to put R3 into her bed. There was a dressing in place to R3's sacrum. There was a pump hooked up to the foot of R3's bed. The pump was not on. R3's feet were placed onto the mattress. At 1:38 PM, R3's air mattress pump was still off. V10 CNA went into R3's room to look at the mattress pump. V10 turned the air mattress pump on, and it made a loud noise. V10 said she did not know what was wrong with R3's air mattress and shut it off. V10 said she will notify maintenance to come look at the mattress. R3's air mattress was still shut off at 2:38 PM and R3 was asleep in bed.On December 9, 2025, at 11:29 AM, V12 CNA said pressure injury prevention interventions include repositioning, laying down, air mattresses, and elevating the residents' feet. At 11:35 AM, there were waffle boots on R3's floor on the side of her recliner.The facility's Wound Care Policy undated shows, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to supervise a resident with a high risk of falls and a history of falls for 1 of 12 residents (R2) reviewed for safety and supervision in the sample of 12.The findings include:R2's Record of admission shows she was admitted to the facility June 7, 2024. R2's Client Diagnosis Report shows she has diagnoses including depression, dysphagia, major depressive disorder, urinary tract infection, dementia, and nondisplaced fracture of lateral malleolus.R2's Fall Incidences shows that she fell five times in the last four months. R2's Fall Risk assessment dated [DATE], shows she is at risk for falls.R2's Care Plan effective October 30, 2025, shows R2 is at risk for falls and R2 self-transfers at times. Alarms on chair and bed to alert staff of unplanned movement and will receive oversight assistance with transfers to reduce the risk of falls.On December 8, 2025, at 1:33 PM there was a chair alarm going off in R2's room. V16 Certified Nursing Assistant (CNA) went into R2 room. R2 was transferring herself from her wheelchair to the toilet. V16 told R2 she's not supposed to get up on her own and R2 said she has to go to the bathroom. V16 shut off R2's alarm and then left R2's room after shutting R2's bedroom door (leaving R2 alone in the bathroom). On December 9, 2025, at 11:29 AM, V12 CNA said that R2 should not be left in her bathroom alone. V12 said that R2 does not always remember to use the call light.The facility's Fall Prevention Policy revised on January 12, 2023, shows, Interventions will be implemented for those residents assessed at risk for falls. These measures will be documented in the Plan of Care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer medications as ordered. There were 28 opportunities with three errors resulting in a 10.71% error rate. This applies to two of five residents (R30, R24) observed in the medication pass. The findings include:1. R30's Record of admission shows she was admitted to the facility on [DATE].R30's Client Diagnosis Report shows she was admitted to the facility with diagnoses including dementia, alcohol use with alcohol induced persisting dementia, anemia, hypertensive heart and chronic kidney disease with heart failure, moderate protein malnutrition, Alzheimer's disease, major depressive disorder, delusional disorder, hypokalemia, anorexia, and dementia.R30's Medication Record dated December 1, 2025-December 31, 2025 shows orders for phosphorus/potassium/sodium give one packet by mouth four times daily at 8:00 AM, 12:00 PM, 5:00 PM, and 8:00 PM and calcium 600 mg (milligrams) + vitamin D3 20 mcg (micrograms) daily.On December 8, 2025, at 10:34 AM, V11 Licensed Practical Nurse (LPN) was preparing medications to administer to R30. V11 administered calcium 600 mg + vitamin D3 10 mcg. (Order was for calcium 600 mg + vitamin D3 20 mcg). V11 also administered R30's 8:00 AM dose of phosphorus/potassium/sodium at 10:34 AM. 2. R24's Record of admission shows she was admitted to the facility on [DATE].R24's Client Diagnosis Report shows she was admitted to the facility with diagnoses including traumatic subdural hemorrhage, atrial fibrillation, Alzheimer's disease, anorexia, dementia, anxiety disorder, major depressive disorder, osteoarthritis, delusional disorders, and poly-osteoarthritis.R24's Medication Record dated December 1, 2025-December 31, 2025, shows acetaminophen 325 mg give 650 mg by mouth three times per day at 8:00 AM, 12:00 PM, and 5:00 PM. On December 8, 2025, at 10:20 AM, V11 LPN administered R24's 8:00 AM scheduled dose of acetaminophen. R24's next scheduled dose was at 12:00 PM.The facility's Medication Administration Policy not dated shows, Medications are administered as prescribed, in accordance with good nursing principles and practices and only by persons legally authorized to do so. Medications are administered in accordance with written orders of the attending physician. Medications are administered within 60 minutes of scheduled time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to identify a pressure wound before developing into an unstageable pressure injury for one (R1). The facility also failed to prevent the development of three facility acquired State 2 pressure ulcers and one facility acquired unstageable pressure ulcer, a Stage 2 pressure ulcer worsening to unstageable, prevent cross contamination during dressing changes and apply pressure reduction devices for one (R2). This failure applies to two of three residents (R1 & R2) reviewed for pressure on the total sample of three. The findings include:1. The Physician Orders for August 2025 for R1 showed he was admitted to the facility on [DATE]. The facility's Body Check Form dated 8/14/25 for R1 documented R1 did not have a pressure injury to his coccyx.A Note dated 8/26/25 at 10:27 PM for R1 documented, R1 has a wound to the coccyx. It was covered with a dressing. Will notify power of attorney - POA tomorrow and do documentation. Initiated treatment to clean and cover. The Note dated 8/27/25 at 2:19 PM from V5 Nurse Practitioner stated to cleanse the wound with wound cleanser, apply, collagenase ointment and cover with a foam dressing daily.The Weekly Wound Assessment and Summary dated 8/26/25 for R1 showed a facility acquired unstageable pressure injury that was identified on 8/26/25 when the area was unstageable. The area measured 6.5 cm x 4.5 cm: granulation and slough present to the wound bed. Scant exudate present. The Weekly Summary note dated 8/26/25 for R1 showed there was 40% slough tissue in the center of the wound surrounded by 60 % granulation tissue. Irregular shape and the edges were not defined. Add air mattress and cushion to his wheelchair. Nurse practitioner notified.On 12/7/25 at 1:00 PM V6 Registered Nurse - RN/Wound Care Nurse stated, R1's skin check when he was admitted showed a scar. V6 stated she reviewed R1's admission skin check. V6 stated she works the floor on Mondays and Tuesdays, and she thinks she saw R1 on 8/18/25 but she did not put a note in. V6 stated when she saw R1 he did not have a pressure injury. V6 stated she found the wound on 8/26/25 and it was unstageable when she found it. V6 stated R1's wound was open with slough tissue present, and did not have any depth. V6 stated when she found R1's wound it was superficial and creamy. V6 stated she cleaned the wound, covered it and notified V5 Nurse Practitioner. V6 stated because it was late at night she did not call R1's wife and told V7 Assistant Director of Nursing (ADON) to notify R1's wife the next morning. V6 stated V5 gave orders. V6 stated the therapy department added a cushion on 8/28/25; the air mattress was added on the same date. R1 was started on a supplement and repositioning every two hours to help with healing. V6 confirmed pressure ulcers should be identified prior to becoming a stage two. V6 stated residents' skin is assessed every time staff does a shower. Skin is to be monitored with repositioning and incontinence care. V6 stated all the facilities mattresses are pressure reliving for stage 1 and 2. V6 stated air mattresses are added for residents that are bony, bedridden, not moving, etc.; it is added for prevention. V6 stated R1 was skinny and now that she has thought about it; it would have been a good idea for him.On 12/7/25 at 2:05 PM V5 Nurse Practitioner reviewed R1's notes and stated she saw R1's wound through telehealth and when she saw the wound it was unstageable. V5 stated she couldn't see the wound bed because of the slough. V5 stated R1's wound was identified on 8/26/25 and she gave orders on 8/27/25. V5 stated they do a skin check on admission then skin checks are done twice per week with showers and when skin care is done. If there are any areas of concerns, then staff should alert the nurse. V5 stated she did not have an opinion on what happened for R1 until she talked to V1 Administrator. V5 came back and stated R1 didn't have anything (pressure injury) and then a few weeks later there was an unstageable area. V5 stated this is what she is supposed to say. V5 stated when there is an area of concern it should be identified when the area is red.On 12/7/25 at 4:00 PM, V2 Director of Nursing - DON stated, staff are to monitor skin when providing care. Staff are to monitor skin with changing, washing, etc. V2 stated anything unusual and/or not there previously should be reported to nursing. Areas of redness should be reported to nursing. Stage 1 and Stage 2 should be identified and reported right away. V2 stated R2 had a blister when it was identified. V2 stated in general they put preventative measures in place such as pressure relief mattress, supplements, floating heels, and wound care clinic referral.The Care Plan dated 8/26/25 for R1 showed, resident has unstageable pressure injury to coccyx (identified on 8/26/25). Air mattress to bed. Cushion to chair. Reposition at least every 2 hours as needed.The Minimum Data Set - MDS dated [DATE] for R1 showed severe cognitive impairment; dependent for toileting hygiene, shower/bath, and lower body dressing. Substantial/maximal assistance needed for personal hygiene, and upper body dressing. Transfers and rolling in bed were not attempted due to medical condition or safety concerns. The facility's Pressure Ulcer Prevention Policy Protocol (no date) showed, Plan: Reduce or eliminate pressure. Promote optimum mobility. Prevent skin breakdown. Intervention: Implement change of position on resident individual basis. Use preventive intervention support surfaces (as pressure-relieving heel devices, pillows, chair cushions, pressure relieving mattresses). Use of proper positioning, transferring, and turning techniques. Skin inspections. Manage urinary and/or fecal incontinence. Evaluation: Monitor skin as appropriate.The facility's Pressure Sore Policy (no date) stated residents with pressure sores, skin lesions/wounds will be monitored and documented. When the nurse is aware of pressure sores, skin lesions, wounds, venous ulcers or other skin abnormalities, the area is to be assessed, reported to clinician and documented.2. On 12/7/25 at 10:10 AM V3 Registered Nurse -RN and V4 Certified Nursing Assistant - CNA put on gown and gloves and went into R2's room for the dressing change to his right heel. V3 stated R2 has diabetes and edema; the edema led to a blister on his heel that opened. V3 stated she had seen R2 two days before the blister opened and he didn't have anything on his right heel. V3 stated R2 has a paste impregnated gauze bandage to his right leg/foot. V3 took her scissors and cut the elastic bandage from his right leg and foot. V3 then cut the paste impregnated gauze bandage from R2's right lower leg/foot and discarded it. V3 grabbed the wound cleanser from the table in his room, sprayed R2's right heel and the rest of the adhered dressing came off R2's heel. The dressing had black and yellow substance on it. V3 grabbed the collagenase ointment and applied it with her finger to the heel wound. V3 applied collagenase to two small open areas on R2's right lower leg. V3 applied abdominal pads to R2's right heel and over the two open areas on R2's leg. V3 took the paste impregnated gauze bandage with zinc and applied it to R2 's right heel/foot and lower leg. V3 took the paste impregnated gauze bandage with zinc and applied it to his left foot/heel and lower leg. V3 applied self-adherent elastic wrap over the top of the paste impregnated gauze bandage. V4 held R2's leg during the dressing change. V3 picked up trash in room and discarded it. V3 picked up the wound cleanser, zinc, and her scissors from the table, sat them down on R2's nightstand, removed her gloves, picked up the wound cleanser, scissors and zinc, and left the room. V3 stopped just outside the door of R2's room, sat the wound cleanser, collagenase, and her scissors down on a PPE (personal protective equipment) container, used hand sanitizer and then picked the items up. V3 carried the items to the wound cart and sat them on top of the cart. V3 put the wound cleanser in the cart and the collagenase. V3 grabbed alcohol wipes and cleaned off her scissors. V3 was asked when gloves are to be changed, and she stated she could have changed her gloves between legs. V3 was asked if she could have changed her gloves after removing the soiled dressing and before putting on the clean one for infection control etc. V3 replied yes and said that made sense. V3 stated R2's feet are checked daily; the paste impregnated gauze bandage doesn't come off unless there is a reason to remove them. V3 stated the paste impregnated gauze bandage is done twice a week. The offloading boot was not put back on R2's heel before staff left the room and a soiled blue foot cover was left laying on a table in his room. The foot cover had some type of drainage on the inside of it where his heel would have been. R2 stated staff do not reposition him every two hours; he stated he is transferred from bed to recliner to wheelchair for meals and back to his recliner and/or bed. On 12/7/25 at 1:00 PM, V6 RN/Wound care Nurse stated, R2's pressure ulcer started as a blister on his right heel and was a blister when it was first identified. V6 stated the blister ruptured, the skin fell off, and there was a wound bed that was dry with necrotic tissue. It changed to an unstageable pressure injury, and he went to the wound clinic for that. V6 stated R2 is supposed to have both heels offloaded to prevent a pressure ulcer to the left side too. V6 stated gloves are to be changed during dressing changes/wound care after the old dressing is taken off gloves should be removed, hand sanitizer used, and new gloves applied. This is important to prevent contamination and infection.On 12/7/25 at 4:00 PM, V2 Director of Nursing - DON stated, staff are to monitor skin when providing care. Staff are to monitor skin with changing, washing, etc. V2 stated anything unusual and/or not there previously should be reported to nursing. Areas of redness should be reported to nursing. Stage 1 and Stage 2 should be identified and reported right away. V2 stated R2 had a blister when it was identified. V2 stated in general they put preventative measures in place such as pressure relief mattress, supplements, floating heels, and wound care clinic referral.The Monthly Pressure Injury Report dated November 2025 showed R2 had a stage 2 facility acquired pressure injury to his right buttock that was identified at the facility on 10/2/25. R2 had an unstageable facility acquired pressure injury to his right great toe that was identified on 11/13/25 that was later put at a stage 2. R2 had a facility acquired right heel pressure injury that was identified at a stage 2 on 11/13/25 and changed to unstageable on 11/24/25. R2 had a facility acquired stage 2 right groin pressure injury that was identified at a stage 2 on 11/17/25.The Weekly Wound Assessment and Summary for R2 showed right heel pressure ulcer stage 2 with an onset date of 11/13/25. The measurements on 11/13/25 were 9.0 cm x 10.0 cm; wound bed with granulation tissue; moderate serosanguinous exudate; surrounding skin reddened. The Weekly Summary dated 11/13/25 for R2 showed the blister ruptured to his right heel. The upper half of the skin peeled back and put back over granulation tissue. R1's foot was swollen, and the skin appeared white/macerated from the drainage. Floating heels and a wound clinic referral were recommended.The Weekly Wound Assessment and Summary for R2 on 11/24/25 showed R2's right heel wound was changed to unstageable due to necrotic tissue. The Weekly Summary dated 11/24/25 for R2 showed there was 70 percent dry necrotic tissue in the center of the wound of his right heel that was surrounded by 30 percent granulation tissue. The edges of the wound were dry with some skin from the blister intact. The wound was changed to an unstageable pressure injury. Floating heels, monitoring of swelling to bilateral lower extremities was recommended and wound clinic appointment on 11/25/25.The Physician Order's for R2 showed, 11/23/25 - float heels every shift, Collagenase topical every evening shift weekly on Tuesday and Friday. Apply nickel thick collagenase to right great toe wound. Apply abdominal pad and wrap leg in paste impregnated gauze bandage from toes to bend in knee.The Care Plan dated 11/25/25 for R2 showed, resident has an unstageable pressure injury to his right heel (stage 2 when identified on 11/13/25; became unstageable on 11/24/25). Resident has a stage 2 pressure injury to right buttock (identified on 10/2/25). Reposition resident at least every two hours and as needed. Recliner for repositioning during the day. Resident has a stage 2 pressure injury to the right great toe. No shoes. Reposition at least every two hours. Encourage resident to float heels while in bed.Resident has a stage 2 pressure injury to the right groin (identified on 11/17/25). Reposition resident at least every two hours and as needed. Monitor positioning of briefs. Every pressure injury stated to provide treatment as ordered; monitor and report if ineffective. R2's care plan did not show any behaviors to include refusal of care.The Progress Notes for November 2025 through 12/6/25 for R2 did not show any non-compliance with care.The Minimum Data Set (MDS) dated [DATE] for R2 showed no cognitive impairment; substantial/maximal assistance with rolling in bed; dependent for transfers, toileting hygiene, lower body dressing, and putting on/taking off footwear.The facility's Pressure Ulcer Prevention Policy Protocol (no date) showed, Plan: Reduce or eliminate pressure. Promote optimum mobility. Prevent skin breakdown. Intervention: Implement change of position on resident individual basis. Use preventive intervention support surfaces (as pressure-relieving heel devices, pillows, chair cushions, pressure relieving mattresses). Use of proper positioning, transferring, and turning techniques. Skin inspections. Manage urinary and/or fecal incontinence. Evaluation: Monitor skin as appropriate.The facility's Wound Dressing Change Policy (no date) showed, put on gloves. Remove soiled dressings and discard in appropriate container. Remove gloves, wash hands or use no rinse sanitizer and put on clean gloves. Cleanse wound with prescribed solution. Remove gloves and wash hands with soap and water. Apply prescribed dressings. Date and initial dressing. Remove gloves and assist resident to a comfortable position. Clean and return equipment to designated area.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff wore personal protective equipment when providing a dressing change for 1 of 3 residents (R3) reviewed for wounds in the sample of three.The findings include:On 12/7/25 at 2:25 PM, R3 was laying in bed and V3 Registered Nurse - RN was at bedside with gloves on and had just completed the wound vac dressing change to R3's right knee. V3 did not have a gown on. V6 RN/Wound Care Nurse entered R3's room wearing a gown and gloves to troubleshoot the wound vac dressing. After V3 and V6 left R3's room, R3 stated V3 did not have a gown on when she did her dressing change. On 12/7/25 at 4:00 PM, V2 Director of Nursing stated gown and gloves are to be worn when doing close contact care to prevent contamination and infection. The Care Plan dated 11/6/25 for R3 showed, resident on isolation related to methicillin resistant staphylococcus aureus - MRSA of nares, MRSA of right knee surgical wound revision. Protective personal equipment to be worn during cares.The Physician Orders dated 11/6/25 for R3 showed maintain contact isolation precautions for MRSA in right knee wound every shift.The Minimum Data Set - MDS dated [DATE] for R3 showed no cognitive impairment.The facility Health care Body Check Form dated 12/3/25 for R3 showed she has a surgical wound to her right knee. The wound measured 8.4 cm x 1.6 cm and had 13 cm of tunneling present at 12 o'clock. R3 had a wound vac in place that is changed on Monday, Wednesday, and Friday.The facility's Policy: Infection Control (no date) showed, all staff who have contact with residents and/or their environments must wear personal protective equipment - PPE as appropriate during resident care activities and at other times in which exposure to blood, body fluids, or potentially infectious materials is likely. Wear PPE (e.g. gloves, gowns, etc.) when handling resident care equipment and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids.The Facility's Contact Precautions policy (no date) showed gloves and gown are to be worn if there is contact with or potential contact with body fluids (except sweat), secretions, excretions, and mucous membranes are to be worn when administering direct patient care.The facility's Policy: Enhance Barrier Precautions showed enhance barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employs targeted gown and glove use during high contact resident care activities. High contact resident care activities include: h. Wound care: any skin opening requiring a dressing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff safely transferred a resident who has history of falls. This applies to 1 of 3 residents (R1) reviewed for safety in the sample of 3.
The findings include:
R1's face sheet shows she is a [AGE] year old female admitted to the facility on [DATE] with diagnoses including right hip fracture, hypertension, chronic kidney disease and congestive heart failure.
On 2/18/25 at 9:05 AM, R1 was in her room sitting in her wheelchair. R1 had a dark purple hematoma to her right forehead and bruising surrounding her right eye, and bruising to her right side of her face. R1 said she fell transferring from her bed to the wheelchair. She said V5 (Certified Nursing Assistant-CNA) was on the opposite side of the wheelchair, away from her, and did not apply a gait belt during the transfer. When she stood up she lost her balance and fell on her knees and hit her head on the corner of the bedside table. R1 said she fell at home prior to coming and broke her right hip.
On 2/18/25 at 10:49 AM, V5 (CNA) said she was R1's CNA when she fell. R1 had her call light on to use the bathroom. She said she put on R1's shoes and socks and positioned the wheelchair next to the bed. When R1 stood up, she went down on her knees and her head hit the corner of the bedside table. V5 said R1 is a stand pivot and she did not need a gait belt to transfer. R1 is very alert and not a fall risk, she does not self transfer and uses her call light and waits for staff to assist.
On 2/18/25 at 11:30 AM, V7 (COTA-Certified Occupational Therapist Assistant) said R1 is alert and oriented, she has generalized weakness, is a one person assist for transfers, and is not independent on transfers. Staff should use a gait belt with contact guard assistance, hands on the gait belt, during transfers and walking for safety.
On 2/18/25 at 1:07 PM, V2 (DON) said staff should use a gait belt when transferring a resident and confirmed V5 did not use a gait belt while transferring R1.
R1's Minimum Data Set assessment dated [DATE] shows she is cognitively intact, has limited range of motion to one side of her lower extremity and requires moderate assistance with transfers.
R1's Fall Risk assessment dated [DATE] shows she had a fall on 2/10/25 and fell at home and had surgery for a right femur fracture.
R1's Fall Incident report dated 2/12/2025 documents on 2/11/25 {V5-CNA} reported (R1) fell while transferring from bed to the wheelchair and hit her head with bruising to face. R1 sent out to the hospital for evaluation CT of the head showed a right scalp hematoma.
The facility's undated Fall Policy states, On admission and re-admission a Fall Risk Assessment will be completed, interventions will then be implemented for those residents assessed at risk for falls. These measures will be documented in the plan of care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure resident coffee was served at a safe temperature for 1 of 4 residents (R1) reviewed for safety and supervision in the sample of four. This failure resulted in R1 sustaining second degree burns to her thigh and calf.
The findings include:
The facility's incident report dated 12/31/24 showed R1 spilled coffee on herself on a Sunday (12/29/24). The report showed the physician and nurse practitioner had been notified. The report was completed by V3 (Director of Nurses).
R1's undated record of admission form showed an admission date of 12/13/24 and a discharge date of 12/30/24. R1's facility assessment dated [DATE] showed diagnoses including but not limited to fracture of the right femur, hypertension, anemia, and osteoporosis. The same assessment showed severe cognitive impairment and staff supervision or touch assistance required for eating.
On 1/9/25 at 4:32 PM, V8 (CNA-Certified Nurse Aide) stated he was assigned to R1 the afternoon shift of 12/29/24. V8 said it was his first time working that unit and caring for R1. V8 said R1 was lying in bed and asked for coffee sometime around 4:30 PM. V8 said he did not realize R1 had dementia and she seemed okay to have coffee by herself. V8 said he brought R1 coffee in a covered, styrofoam cup. V8 said he went into her room about 30 minutes later and saw brown coffee stains on her sheets. V8 said he rolled R1 to the side to prepare her for transfer out of bed. V8 said he saw blisters on the back of her upper thigh. The area was blistered about the size of a football and he could tell it was a burn. V8 said he alerted the nurse working the floor (V3-DON-Director of Nurses). V3 assessed the area, applied ointment, and told him to keep her off the area.
On 1/9/25 at 11:22 AM, V3 (DON) stated she was working the evening of 12/29/24 and was alerted by V8 around 4:30 PM or 5 PM that R1 had spilled coffee on herself while in bed. V3 said she went to the room and assessed R1 in bed. The back of R1's upper thigh had a big, long, and good amount sized burn on it. V3 said the skin was open and the first layer of skin was peeling back. V3 said R1 reported pain when it was touched. R1 said she spilled coffee on herself. V3 said R1's cognition was poor. Earlier in the day, R1 had been having difficulty opening her right hand fully and was not able to firmly grasp items. V3 said R1 was on isolation for covid and was eating all her meals in her room.
R1's progress note dated 12/29/24 and authored by V3 showed: Alerted by CNA around 0500pmish (sic) that resident has spilled coffee on herself .Upon rolling the resident towards the wall skin peeling is noted. Rt (right) leg thigh-posterior (back) side was red and skin was noted measuring 14 cm x 5.5 cm (centimeters).
On 1/9/25 at 3:25 PM, V6 (WCN-Wound Care Nurse) stated she cared for R1 the day after the coffee burn on 12/30/24. V6 said she assessed and measured the burns, which had progressed from the assessment done the evening prior. V6 said there were open blisters to the back of her right thigh, knee, and calf. V6 said R1 was also seen by the nurse practitioner and her physician after her assessment.
R1's body skin check form dated 12/30/24 and signed by V6 (WCN) showed: burns from coffee-wound assessments. The form showed two areas on the back of right thigh measuring 14.0 x 5.5 cm and 4.0 x 2.0 cm (centimeters). One area on the back of the right knee measuring 2.5 cm x 2.0 cm. Two areas on the back of the right calf measuring 11.0 x 3.0 cm and 3.0 x 1.0 cm.
On 1/9/25 at 3:08 PM, V5 (Nurse Practitioner) stated she saw R1's burns on 12/30/24 and agreed with the skin assessment done by the wound care nurse (V6). V5 said she recommended R1 be sent out to the local emergency room for evaluation and treatment. V5 said R1's daughter wanted R1 to be seen by the physician first, who was also in the building at that time. V5 said the physician did see R1 shortly after and diagnosed second degreed burns on the right leg. Orders were given for wound treatments and a referral to wound care.
R1's chart note dated 12/30/24 by her physician states: Burn of second degree of unspecified thigh, initial encounter. Patient sustained a burn by spilling coffee on her right leg yesterday. Several blisters present, with the largest one ruptured on the posterior right thigh, exposing subcutaneous tissue with pink color. No other acute inflammatory changes. Recommend silver Silvadene to apply as directed: wound care consult; close monitoring for any early signs and symptoms of infection; notify MD/NP (medical director/nurse practitioner) with any concerns or changes; monitor.
On 1/9/25 at 9:27 AM, V2 (Dietary Manager) stated R1 was burned on her thigh while drinking coffee in bed. V2 verified it occurred on 12/29/24 (Sunday) and he was notified of the incident the same day via the facility's interoffice email system. V2 stated the coffee temperatures are checked every day by himself. V2 said he is at the facility seven days a week, including weekends. V2 said he checks that the coffee is between 175-190*F (degrees Fahrenheit) when it comes out of the machine. V2 said he checks it by pouring the coffee into a cup and placing a stem thermometer into it. The temperature should be at the 175-190 degree range for the proper distribution temperature to serve it. V2 said he does not record any coffee temperatures unless there is an occurrence, like the burn R1 experienced. V2 said he records the temperatures for about one week then stops. V2 said he just assumes the coffee is at a safe level based on the machine temperature and that it drops to the proper serve temperature prior to leaving the kitchen. At 9:46 AM, this surveyor and V2 tested the hot water coming out of the coffee machine using a thermometer that had been observed calibrated to 32*F in an ice bath. The water registered 178.5*F. V2 said it was the same water source used to make resident coffee.
On 1/9/25 at 10:05 AM, the last three months of coffee temperature monitoring logs were requested. The only log available was dated from 12/29/24 to 1/7/25 (week following R1's thigh burns). Temperatures ranged from 176*F to 189*F.
On 1/9/25 at 1:33 PM, this surveyor entered the facility kitchen and V7 (outside service technician) was at the coffee machine with hand tools. V7 said he was just called that day to come in and lower the water temperature on the machine. V7 said it's running too hot and they want it turned down to serve it at a lower temperature.
On 1/9/25 at 1:37 PM, V2 (Dietary Manager) said the technician was called in today even though the coffee was being served at the proper temperatures. At this interview, the dietary manager gave entirely different temperature levels and testing procedure. V2 said the coffee should be tested when it comes out of the machine, again after resting in the carafes, and third time after poured into the serving cups. The temperatures should be 175-190 at the machine, 170-160 in the carafes, and 145-150 in the serve cups.
On 1/9/25 at 4:45 PM, temperatures of the coffee were taken by V2 prior to serving for the dinner meal. At 4:50 PM, the coffee coming out of the machine was 153*F. At 5:05 PM, coffee in the carafes was at 135*F. V2 stated the carafes will be left open and allowed to rest until the temperature drops. At 5:30 PM, coffee was poured into serving cups and was at 129*F. V2 said any coffee served will be tested and recorded like this going forward. The temperatures will be taken at every meal and documented on the log. Any coffee temperatures higher than allowed with be left in the kitchen until it cools down. V2 said every cook will be trained on the procedure. The day cook has been trained already, the evening cook and any cooks in training will be trained tomorrow.
The facility's undated Coffee Machine Temperature Monitoring Policy states under the procedure section: Designated dietary staff member will monitor coffee machine to assure it is operating within normal temperature limits. The facility's undated Hot Liquid Policy states under the guideline section: 2. The temperatures of hot liquids will be checked that they are in range by the dietary department .3.e. Disallow hot liquids while lying in bed.
The facility was unable to provide any policy related to normal coffee temperature limits. The facility was unable to provide any policy related to when and how to monitor hot liquid temperatures.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R25's record of admission shows she was admitted to the facility on [DATE]. Her physician order sheet for October 2024 shows an order for a right heel wound dressing daily, and an indwelling catheter. The orders do not include enhanced barrier precautions.
On 10/8/24, R25 was observed sitting in her room with her husband. Her wheelchair had a catheter drainage dignity bag hanging below her seat. The door to her room did not have any signs for enhanced barrier or contact isolation requirements. R25's husband stated there was a catheter present, and a wound to R25's foot.
On 10/10/24 at 9:14 AM V9 CNA said she was responsible for R25's care for her shift. She said R25 was not on any type of isolation, and she did not need to put on any PPE (Personal Protective Equipment) such as a gown. She said R25 has an indwelling catheter and is changed to a leg bag everyday. V9 went to the desk to refer to a list of residents and isolation requirements, and said R25 was not on the list.
On 10/10/24 at 10:30 AM, V1 said the doctors will determine what type of isolation a resident requires. We do have enhanced barrier precautions, we went ahead and placed residents on contact isolation, such as those with wounds and catheters.
The facility's undated policy for Enhanced Barrier Precautions documents it is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multi-drug-resistant organisms. 2. Initiation of Enhanced Barrier Precautions: b. An order for enhanced barrier precautions will be obtained for residents with any of the following: i. Wound ( such as pressure ulcers) and/or indwelling medical devices (e.g. urinary catheters) even if the resident is not known to be infected or colonized with a MDRO (Multi-drug-resistant organism).
Based on observation, interview, and record review the facility failed to perform incontinence care in a manner to prevent cross contamination (R15), failed to initiate enhanced barrier precautions for a resident with an indwelling catheter and open wounds (R25), and failed to administer medications in a manner to prevent cross contamination (R18) for 3 of 3 residents (R15, R25, and R18) reviewed for infection control in the sample of 14.
The findings include:
1. R15's Client Diagnostic Report, provided by the facility on 10/10/24 showed she had diagnoses including, but not limited to, chronic diastolic (congestive heart failure, chronic kidney disease, venous insufficiency, anemia, ulcerative (chronic) pancolitis, diarrhea, acute kidney failure, essential tremor, Alzheimer's disease, and dementia. R15's facility assessment dated [DATE] showed she had short-term and long-term memory problems, and moderate cognitive impairment. The assessment showed R15 was dependent on staff for toileting and bathing and was at risk of developing pressure injuries. R15's Physician's Orders show apply calmoseptine to buttocks and coccyx twice daily for protection. The orders also show Proheal (protein supplement) Give 30 milliliters twice daily to support improved skin integrity. R15's Plan of Care, provided by the facility on 10/10/24 showed she is at risk for skin breakdown related to bowel/bladder incontinence. The plan of care showed to monitor the skin for any changes i.e., dry spots, red areas. The plan of care showed R15 needs extensive assistance with two staff for bed mobility and toilet use related to weakness and deconditioning.
On 10/10/24 at 9:59 AM, V10 and V11 (Certified Nursing Assistants-CNAs) provided incontinence care for R15. V10 and V11 rolled R15 onto her right side to remove her pants and incontinent brief. Stool was observed above the top of R15's brief in the back. V10 and V11 rolled R15 onto her back side and removed the soiled brief. non-formed liquid stool was also observed in R15's pubic and groin areas. V10 used a wet wipe to wipe across R15's pubic area, then down her left groin area in one motion. V10 grabbed another wet wipe and wipe R15's pubic area, then down her right groin in one motion. V10 grabbed a wet wipe and wiped R15's left groin, then her vaginal area using the same wet wipe, the same side of the wipe. V10 and V11 rolled R15 back onto her right side. V10 grabbed a few wet wipes from the package and wiped the stool from R15 in a back to front motion. repeating this direction two more times using the same wet wipes. At 10:19 AM, V11 was asked if she would have done anything different during care. V11 said she she would have used a different wipe for each area, and she would have wiped front to back, not back to front to prevent cross-contamination and prevent infection. At 10:23 AM, V10 said she should have used a clean wipe for each area, and she should have wiped front to back, so she did not spread bacteria to the opening of R15's vaginal area.
The facility's undated policy and procedure titled Perineal Care showed Prolonged exposure to urine and feces produces excessive hydration of the sin which causes increased coefficient of friction, increased epidermal permeability and increased microbial flora. the interaction of urine and feces increases the ph of the skin. All these factors compromise skin integrity/Infections. The policy and procedure showed Procedure: Wash all areas that may come in contact with urine and/or stool. Wash with soap and water. Wipe skin gently using a front to back motion. Repeat if necessary. Always remember that when you touch dirty, you must change your gloves.
3. R18's face sheet showed she was admitted to the facility on [DATE] with diagnoses to include congestive heart failure, Type 2 Diabetes, hyperlipidemia, and hypertension.
On 10/10/24 at 8:16 AM, V5 LPN (Licensed Practical Nurse) was passing medications in the dining room. V5 was preparing R18's medications at the cart. V5 pushed each individual medication from the residents medication card directly into her hand and then dropped the pills into the medication cup.
On 10/10/24 at 9:21 AM, V2 DON (Director of Nursing) said the nurses should never touch any medication, it should be put directly into the medication cup because you never know what is on your hands.
The facility's undated policy and procedure titled Medication Administration showed, . 12. Remove medication from source, taking care not to touch medication with bare hand .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's physician was notified when blood glucose levels were out of the set parameters ordered by the physician for 1 of 1 resident (R5) reviewed for blood glucose levels in the sample of 14.
The findings include:
R5's Physician's Orders, provided by the facility on 10/10/24, showed an order dated 5/21/24 for Accucheck (blood glucose check) twice daily. Call doctor if greater than 250 or less than 70. R5's Plan of Care, provided by the facility on 10/10/24, showed she has the potential for hyperglycemic or hypoglycemic (high and low blood glucose level episodes secondary to diabetes). The plan of care showed to Monitor blood sugar levels per MD/NP (Doctor/Nurse Practitioner) order, notify MD/NP of abnormal findings with follow up as indicated. R5's facility assessment dated [DATE] showed she had short-term and long-term memory problems, moderately impaired cognitive skills, was dependent on staff for all activities of daily living, except eating, and had a diagnosis of type II diabetes mellitus.
R5's Blood Glucose Report from July 9, 2024, through October 9, 2024 were reviewed. The report showed the following days with blood glucose levels outside the parameters set by R5's physician:
7/15/24 290
7/16/24 281
7/17/24 288
7/20/24 270
7/21/24 301
8/5/24 322
8/13/24 371
9/1/24 321
9/23/24 292
10/8/24 318
10/9/24 273
On 10/9/24, R5's Nurse Progress notes and mediprocity notes (communication portal between the facility and the physicians/nurse practitioner) were requested for the above listed days. The notes showed no documentation of R5's doctor or the nurse practitioner being notified of R5's blood sugar levels on 7/15/24, 7/16/24, 7/17/24, 7/20/24, 9/1/24, 9/23/24, 10/8/24, or 10/9/24.
On 10/10/24 at 8:20 AM, V1 (Administrator) was provided the list of days showing blood glucose levels out of the parameters order by R5's physician, and asked to show documentation that R5's Doctor or the NP (nurse practitioner) was notified. V1 said she thinks what was already provided is all they found; however they would keep looking. At 1:21 PM, V1 said no further information showing that the doctor or the nurse practitioner had been updated had been provided to her.
At 1:58 PM, V1 said she spoke with the nurse's that were working on the days listed, to see if they could find any documentation. V1 said V2 (Director of Nursing-DON) and the nurses did not provide her with any further documentation than what she already provided this surveyor. V1 said she expects the nurse on duty to call the doctor, not use mediprocity to communicate, and to report blood glucose levels above 250 for R5, adding, that is what her orders say-to call the doctor.
The facility's undated policy and procedure titled Hypoglycemia/Hyperglycemia showed, Hyperglycemia-resident: 1. Check the victim's [sic] capillary blood glucose level with an accu-check. Assess resident condition for signs and symptoms of hyperglycemia .2. Be aware of any infections, or changes that would be useful information to share with the physician. 3. Notify physician of condition change and follow orders .5. document condition, interventions and response in resident's record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R15's Client Diagnostic Report, provided by the facility on 10/10/24 showed she had diagnoses including, but not limited to, chronic diastolic (congestive heart failure, chronic kidney disease, venous insufficiency, anemia, ulcerative (chronic) pancolitis, diarrhea, acute kidney failure, essential tremor, Alzheimer's disease, and dementia. R15's facility assessment dated [DATE] showed she had short-term and long-term memory problems, and moderate cognitive impairment. The assessment showed R15 was dependent on staff for toileting and bathing and was at risk of developing pressure injuries. R15's Physician's Orders show apply calmoseptine to buttocks and coccyx twice daily for protection. The orders also show Proheal (protein supplement) Give 30 milliliters twice daily to support improved skin integrity. R15's Plan of Care, provided by the facility on 10/10/24 showed she is at risk for skin breakdown related to bowel/bladder incontinence. The plan of care showed to monitor the skin for any changes i.e. dry spots, red areas. The plan of care showed R15 needs extensive assistance with two staff for bed mobility and toilet use related to weakness and deconditioning.
On 10/10/24 at 9:59 AM, incontinence care was observed for R15. R15 had dark discoloration on both her left and right buttocks that blanched when pressure was applied during care. No open areas were observed during care.
The untitled document provided by the facility on 10/10/24, showed on 7/21/24 six open areas were identified on R15's left buttocks (3), right buttocks (2) and coccyx area (1). The document showed the open areas were all stage II pressure injuries.
R15's wound assessments were reviewed showing assessments were completed on 7/21/24 and 7/24/24. R15's progress notes showed she had been sent out to the hospital on 7/24/24 (not related to the pressure injuries) and returned to the facility on 7/31/24. The next assessment provided by the facility of R15's wounds was on 7/31/24. There was no assessment provided by the facility to show any assessments done on R15's pressure wounds, after the 7/31/24 assessment until 8/13/24 (13 days later). The next assessment provided by the facility for R15's pressure wounds was on 8/29/24 (16 days later). The next assessment provided by the facility of R15's pressure wounds was on 9/8/24 (10 days later). the next assessment provided by the facility of R15's pressure wounds was on 9/17/24 (9 days later). The next assessment provided by the facility of R15's pressure wounds was on 9/30/24 (13 days later).
R15's Interdisciplinary Progress Notes (IPN) and Mediprocity Notes (communication portal between the facility and the doctors/nurse practitioner) were reviewed from 7/21/24 through 9/30/24. Assessments for R15's pressure wounds in Mediprocity Notes were on 7/21/24, 7/31/24, 8/13/24. There were no wound assessments in R15's Interdisciplinary Progress Notes, other than to document when one of the six pressure wounds was resolved. The other existing wound assessments were not documented on those days in the IPN notes.
On 10/10/24 at 9:03 AM, V4 (RN/Wound Nurse) said R15 had bad diarrhea and she thinks that contributed to the skin breakdown. V4 said R15 was sent out to the hospital on 7/24/24 and returned to the facility on 7/31/24. V4 said the six pressure injuries were identified on 7/21/24. V4 said interventions had been in place prior to R15 developing the pressure injuries. V4 said she had been on vacation from 7/13/24-8/25/24. V1 (Administrator) was present during the interview and at 9:14 AM, she said R15 had high comorbidities. V1 said R15 had a decline at the time she developed the pressure injuries. V1 (Administrator) said R15 was sent out to the hospital and came back to the facility more deconditioned than when she left.
On 10/10/24 at 9:26 AM, V4 said It does not look the assessments were done weekly after they were identified. It is important to make sure they are done to monitor progress and deterioration of the wound, and to update the Doctor, to see if new orders are needed. This surveyor requested a copy of all the assessments for the pressure injuries for R15 from 7/21/24-9/30/24 (when the last of the pressure injuries were resolved).
On 10/10/24 at 10:44 AM, V1 (Administrator) brought the assessments for R15's pressure injuries to her buttocks/coccyx areas. The assessments provided to surveyor were dated:
7/21/24; 7/24/24; 7/31/24; 8/13/24; 8/29/24; 9/8/24; 9/17/24; and 9/30/24.
On 10/10/24 at 1:21 PM, V1 said she believes she has provided all of the assessments that the facility has to provide for R15's pressure injuries.
The facility's undated policy and procedure titled Wound Management Policy showed Residents with pressure sores, skin lesions/wounds will be monitored and documented. The policy showed 3. Documentation of pressure sores and other skin conditions must include A. Characteristics (i.e. size, shape, depth, color, slough, presence of granulation tissue, necrotic (non-viable skin) tissue). B. Treatment.
Based on observation, interview, and record review the facility failed to assess pressure wounds weekly for 2 of 4 residents (R23, R15) reviewed for pressure ulcers in the sample of 14.
The findings include:
1. R23's face sheet showed he was admitted to the facility on [DATE]. R23's client diagnoses report printed 10/10/24 showed R23 had diagnoses of orthopedic aftercare following surgical amputation, atrial fibrillation, atherosclerotic heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, and Alzheimer's disease.
R23's care plan initiated 6/26/24 showed, Resident has a Stage 3 Pressure Injury to right hip . Observe for changes in pressure ulcer, report to MD if there is an increase in size or stage and follow up as indicated .
R23's 6/25/24 wound assessment showed a wound to R23's right hip was identified on 6/24/24 and the first assessment was completed 6/25/24. R23's next wound assessments were completed as follows: 7/7/24 (11 days between assessments), 7/31/24 (24 days between assessments), 8/9/24 (9 days between assessments), 8/28/24 (19 days between assessments), 9/8/24 (12 days between assessments), 9/17/24 (9 days between assessments), and 9/29/24 (12 days between assessments).
On 10/09/24 at 1:59 PM, V4 (Wound Care Nurse) said, I usually do the measuring once a week. I document on paper sheets and we scan them into the residents record under documents. If am off like I was this summer, our Infection Preventionist nurse did them. They would all be in the record under documents. I do weekly assessments monitor the progress of the wound and see if there is anything that needs to be changed. [R23]'s wound assessments were done 6/25/24, 7/7/24, 7/31/24, 8/9/24, 8/28/24, 9/8/24, 9/17/24, 9/29/24, and 10/6/24.
On 10/10/24 at 9:27 AM, V2 DON (Director of Nursing) said they typically assess and measure wounds weekly. [V4] does them but if she is not here our floor nurses are very good with wounds too and we ask the floor nurse to measure.
The facility's undated policy titled Wound Management Policy showed, Responsibility: Charge Nurse, or Director of Nursing or designee . Residents with pressure sores, skin lesions/wounds will be monitored and documented .

Based on observation, interview and record review, the facility failed to ensure staff covered an open wound, and failed to ensure food was prepared and served in a sanitary manner.
These failures have the potential to affect all of the residents in the facility.
The findings include:
The CMS Long-Term Care Facility Application for Medicare and Medicaid form CMS-671 dated 10/8/24 showed 39 residents resided in the facility.
The facility's undated list of residents' Diet Orders, provided by the facility on 10/10/24 showed all 39 residents take food by mouth. No residents on the list had a feeding tube.
On 10/8/24 at 9:57 AM, V6 (Dietary Manager) was preparing the lunch meal. V6 said he and V12 (Cook) were both preparing the lunch meal. V6 had an open wound to his right inner forearm that was not covered. There was a small smear next to the open wound that appeared to be blood. At 12:11 PM V6 obtained the food temperatures prior to serving. V6 still had the open wound uncovered. At 12:27 PM, V6 was asked about the wound on his right inner forearm. V6 said he scratched himself on something. V6 was asked what the facility's policy was on open wounds, and if he should cover the area. V6 said he could cover it.
On 10/8/24 at 12:11 PM, V12 (Cook) was asked to take the temperatures of the foods on the steam table. V6 (Dietary Manager) walked up and said he (V6) would check the food temperatures. V6 grabbed a sanitation bucket and placed in on the steam table. V6 picked up the food thermometer and dipped it into the sanitation bucket, then ran the thermometer across the washcloth that was on the side of the sanitation bucket. V6 took the temperatures of the 5 different chicken food consistencies, then dipped the thermometer back into the sanitation bucket and ran the thermometer across the washcloth. V6 took the temperatures of the regular noodles and the pureed noodles and then dipped the thermometer back into the sanitation bucket and across the washcloth. V6 repeated this process to clean the thermometer 4 more times in between different food items.
On 10/08/24 At 12:24 PM, V6 was asked to test the chemical sanitation level in the sanitation bucket. V6 used a Hydrion QT-40 test strip to test the sanitation level. The test strip was yellow after dipping into the bucket. V6 said the test result was between 150 ppm (parts per million) and 200 ppm. V6 was asked if he was sure about that because the test strip was yellow. V6 insisted that the results were between 150 ppm (parts per million)-200 ppm, adding that he could see a hint of green on the test strip. V7 (dietary aide) was walking by. This surveyor asked V6 if V7 had worked at the facility a long time. V6 said yes. V7 was asked to look at the test strip that V6 had against the test strip container, and asked if it looked light green in color, or close to the 150 ppm color. V7 said No, not at all, it is yellow. (For reference: The first color on the chart to compare the test strip to is orange, which is zero ppm; the second color on the chart is a light green, which is 150 ppm; the remaining three colors on the chart are darker shades of green showing 200 ppm-500 ppm of chemical sanitation).
On 10/10/24 at 9:41 AM, V6 was said the facility's policy for open wound is to have the wound covered while working. Needs to be covered without draining. V6 said he did not have the area on his arm covered the other day. V6 said he should have had it covered to make sure that no bodily fluids contaminate the area or the food. At 9:46 AM, V6 was asked about dipping the thermometer into the sanitation bucket to clean between taking the temperatures of the food items on the steam table on 10/8/24. V6 said in previous inspections the facility used alcohol wipes for cleaning the thermometer and was advised to do it differently. V6 said that was years ago, so we went to using the sanitation bucket with quat (quaternary Ammonium Compound) sanitizer. V6 said he should have checked the sanitation level of the bucket prior to using.
On 10/10/24 the facility provided their undated policy and procedure titled Quat Sanitizer Testing Policy. the policy showed Quat sanitizing solution dispenser will be tested daily by dietary manager .Quat sanitizer solution for surface sanitizing will be changed every four hours or when visibly soiled to assure effective concentration. The facility also provided instructions for the hydrion QT-40 test strip. The instructions showed EPA-registered sanitizer for use on hard, non-porous food prep surfaces and wares, kills foodborne organisms as listed on product label. The instructions showed uses for the sanitizer were for a three-comparment sink sanitizer and food contact surface sanitizer.
The facility's undated policy titled Dietary Staff Wound Policy showed Dietary staff will cover any open wound with adequate dressing to avoid contact and/or seepage. Additional coverage may be required and provided dependent on location of wound, i.e. finger cut, wrapping, etc.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure fall interventions were in place for residents with a history of falls for 2 of 3 residents (R2, R3) reviewed for safety and supervision in the sample of 3.
The findings include:
1. R2's Fall Risk assessment dated [DATE] showed R2 had eight (8) falls in the facility from 2/2/24-3/27/24. The assessment showed the facility utilized chair and bed alarms as fall interventions for R2.
R2's current care plan showed R2 remained at high risk for falls related to her unsteady gait, history of previous falls, and diagnosis of dementia with behaviors. The care plan listed alarms on chair and bed to alert staff of unplanned movement as one of R2's fall interventions since 3/1/23.
On 3/28/24 at 9:50 AM, R2 was in bed. R2's upper body (head, torso, buttocks) were on the bed. R2's legs were off the bed, propped up on the seat of a wheelchair, that was positioned next to R2's bed. No mats were noted on the floor next to R2's bed. Folded floor mats were noted against the wall, by the foot of R2's bed. A pad alarm was placed partly under R2's buttocks and partly hanging off R2's bed. The cord attached to the pad was not connected to the alarm box. The cord laid on the floor, under R2's bed. The alarm box was turned off, hanging off the siderail of R2's bed.
On 3/28/24 at 11:30 AM, R2 was in bed, with her entire body positioned in the bed. The pad alarm was in place, under R2 and turned on. V4 (Family of R2) was seated in a chair, next to R2's bed. V4 stated that when he arrived that morning, he too found R2 with her upper body in bed and her feet in a wheelchair next to the bed. He also found R2's pad alarm had been disconnected and turned off. V4 stated, That happens a lot. When I come in and the alarm isn't on. She needs the alarm. She has a weak back and is constantly moving around, trying to get comfortable. When she moves around, she falls out of bed. She just fell out of bed again last night.
On 4/1/24 at 9:07 AM, V8 Licensed Practical Nurse stated R2 should have a pad alarm or clip alarm in place due to her risk of falls. V8 also stated R2 is to have mats lying on the floor next to her bed anytime R2 is in bed.
2. A Facility Census Form dated 4/1/24 showed R3 resided in a room, on the skilled care/intermediate care wing, from 12/20/23-3/29/24.
R3's progress notes dated 1/1/24-3/29/24 showed R3 had three (3) falls in the facility on 1/21/24 (2 falls) and 1/25/24. A note dated 1/21/24 at 7:41 PM showed R3 fell as he was trying to get out of his recliner. A note dated 1/25/24 showed clip and bed alarms had been placed on R3 as fall interventions.
R3's current care plan showed R3 remained at risk for falls due to his history of previous falls, unsteady gait, and the amputation of toes to his right foot. The plan showed, Clip and bed alarm in place to alert staff of any unplanned movement.
On 3/28/24 at 9:56 AM, R3 was seated in a recliner in his room. No pad alarm was noted under R3. No clip alarm was attached to R3. A clip alarm was noted hanging off the handle of a wheelchair in R3's room. The clip alarm was turned off.
On 4/1/24 at 9:39 AM, V2 Director of Nursing stated floor mats and position alarms are used as fall interventions for residents in the facility. V2 stated, If a resident is at high risk for falls, we do use bed/chair alarms and floor mats next to their beds as fall interventions. We also try to keep them in view of our staff. CNAs (certified nursing assistants) should be checking many times during their shift to make sure alarms are in place and working. If a resident needs an alarm, it's documented on their care plan.
The facility's Fall Policy (undated) showed, On admission and re-admission, a Fall Risk Assessment will be completed. Interventions will then be implemented for those residents assessed at risk for falls. These measures will be documented in the Plan of Care .
The facility's Fall Prevention Program policy (undated) listed assisted devices/alarms and low bed/mat on the floor as fall interventions used in the facility.

Based on observation, interview, and record review, the facility failed to ensure pressure ulcer preventions were in place and failed to ensure ordered treatments were in place for one of four residents (R89) reviewed for pressure injuries in the sample of 15.
The findings include:
R89's Physician Orders Sheet dated December 1, 2023-December 31, 2023 shows orders were entered on December 11, 2023 for: Float heels every shift, discoloration to left heel-paint with betadine, cover with foam dressing every evening shift, and buttocks wound area-cleanse with wound cleanser, apply A & D ointment, cover with abdominal dressing every evening shift.
R89's Care Plan effective December 11, 2023 shows, Resident has stage I pressure injury to right buttocks and stage II pressure injury to coccyx. Treatment as order, monitor and report if ineffective. December 18, 2023-float heels with heel protectors or pillow when in bed as needed.
R89's Body Check form dated December 11 & 13, 2023 shows R89 had wounds to her buttock and left and right heel.
On December 18, 2023 at 1:26 PM, V4 CNA (Certified Nursing Assistant) and V3 CNA supervisor transferred R89 from her chair and into the bed. R89 had white canvas tennis shoes on. When V4 removed R89's tennis shoes, R89 said ouch. There were multiple open areas to R89's buttocks/sacral areas. There was no dressing present to R89's buttocks. V4 said R89 has been up in her chair since about 8:00 AM. R89 complained of pain to her buttocks when V4 cleansed it. V3 placed A & D ointment to R89's buttocks, but did not place a dressing on it. R89's clean incontinence brief was applied. V3 placed a pillow under R89's calves. R89's heels were on the mattress. There was a heel boot on R89's dresser.
On December 19, 2023 at 10:06 AM, R89 did not have dressings in place to her left heel or buttocks. V5 CNA said she had just put R89 into the bed. V5 said that R89 was wearing the white tennis shoes. V6 WCN (Wound Care Nurse) came into R89's room to perform dressing changes to R89's pressure injuries. There was no dressing in place to R89's left heel or buttocks. V5 said she removed the dressings when she had R89 in the shower before breakfast. V6 said he was not aware that R89 did not have dressings in place. Treatments were performed. There was a new dark red area to the tip of R89's left big toe. V6 said that was a new area V6 said the area looks like a new deep tissue injury. V5 CNA placed a pillow under R89's legs. R89's heels were still on R89's bed. There was a heel boot on R89's dresser.
On December 20, 2023 at 9:21 AM, V19 CNA said that R89 does not wear heel boots. V19 said that R89 wears the white tennis shoes everyday. At 9:32 AM, V3 said R89's heels should not be touching the bed when they are floating. V3 said they do not use heel boots for R89.
V13's NP (Nurse Practitioner) note dated December 20, 2023 shows, Stage II pressure injury to coccyx. Wound is 2.5 cm (centimeter) X 1.0 cm X 1.0 cm. Defined edges with surrounding skin 4 cm X 5 cm non-blanching area. Cleanse area with wound cleanser, apply A & D ointment to wound and surrounding area, cover with foam dressing daily. Deep tissue injury left heel: Continue to paint area with betadine, cover with foam dressing daily. Float heels while in bed. Left great toe deep tissue injury: Cleanse area, apply betadine to toe, cover with foam dressing until resolved. Staff informed to call family to bring in soft shoes.
The facility's undated Wound Care Policy shows, To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change.

Based on observation, interview and record review the facility failed to ensure food was stored, prepared and distributed in a manner to prevent cross-contamination, failed to ensure food items in the refrigerator and freezer were labeled and dated with an open date and failed to ensure that kitchen was kept in sanitary condition. This applies to all 36 residents residing in the the facility.
The findings include:
The Resident Roster printed on 12/18/23 shows there are 36 residents residing at the facility.
On 12/18/23 at 8:37 AM, there was an open bag of cranberry sauce and an unlabelled bag of a half angel food cake in the freezer. In the refrigerator there was a dried pink substance splattered on a bag of mozzarella cheese and on the lid of a mayonnaise container. There was a dried pink substance on the shelf of the refrigerator. There was a white liquid under the jar of mayonnaise and food debris scattered throughout the bottom of the refrigerator. In the walk in refrigerator there was an unlabeled plastic bag of roast beef, an unlabeled, uncovered tray of apple crisp, an unlabeled, uncovered tray of chocolate cake and a tray of unlabeled, uncovered small cups of salad dressing. In the dry storage are there were boxes of food on the floor. V17 (Dietary Manager) said that they were delivered on Friday (3 days prior). There was multiple fruit flies observed in the dishwasher area and near the juice machine. The juice machine drip pan was half filled with juice. There was dried sticky juice on the floor beneath the juice machine. There was multiple areas of food debris seen on the floor throughout the kitchen. There was a canister vacuum with white powdered substance on the top of it sitting next to the food preparation table.
On 12/18/23 at 10:30 AM, V17 prepared the pureed lunch. After pureeing the noodles, V17 placed the noodles from the food processor bowl into a container. While he was transferring the noodles, liquid from the underside of the food processor was dripping into the container. V17 then pureed the carrots and when he was transferring them from the food processor bowl to the container, liquid was dripping into the container. V17 said, That's just sanitizer agent from the dish machine dripping out.
On 12/18/23 at 12:00 PM, V17 started serving the noon meal from the steam table in the kitchen Above the steam table were three fans. The grille of the fans had a thick layer of brown/gray debris on them with strings of the debris blowing out of them. Four ceiling tiles in front of the fans had multiple pieces of brown/gray debris or them. V17 plated and served the noon meal using multiple (more than 10) chipped plates. The chips were observed on the top serving surface of the plates.
On 12/18/23 at 2:00 PM, V17 said that food in the refrigerator or freezer should be covered or in a closed container or bag and the food should be labeled with the date it was prepared and the item name. V17 said that chipped plates should not be used especially if the chip is on the serving surface. V17 said that they do have a cleaning schedule and a different area of the kitchen is cleaned weekly but he does not have a log of when it was cleaned.
The facility's undated Food Safety Requirements Policy shows, Dry food storage-keep foods/beverages in a clean, dry area off the floor .Safe refrigerated storage include: .Labeling, dating, and monitoring refrigerated food Keeping foods covered or in tight containers All equipment used in the handling of food shall be cleaned and sanitized, and handled in a manner to prevent contamination
The facility's undated Kitchen Sanitation Policy shows, All food service areas shall be kept clean, sanitary and free from liter and rubbish .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure staff used required personal protective equipment (PPE) when entering an isolation room, failed to perform hand hygiene to prevent cross contamination and failed to ensure residents and staff were tested for COVID-19 to prevent the spread of infection. This applies to all 36 residents residing in the facility.
The findings include:
1. A Resident Roster dated 12/18/23 shows that there are 36 residents residing in the facility.
An undated facility provided list of residents who were COVID positive shows that a resident on the 200 Hall tested positive for COVID-19 on 11/13/23. The list shows that 20 residents on the 100 Hall and 200 Hall tested positive between 11/13/23 and 11/24/23. The list shows that by 11/16/23 there were residents on all hallways testing positive.
On 12/19/23 at 10:30 AM, V1 (Administrator) said that the COVID-19 outbreak started on 11/13/23 and all staff and residents were tested on the 11/14/23 and 11/15/23. V1 said that there were multiple staff and residents throughout the facility that tested positive on those days. V1 said that they originally started contact tracing for testing but then resident and staff were coming up positive facility wide so they started testing facility wide. V1 said that they test all agency staff prior to their work day but the facility's staff do not get routinely tested because they wear N95 masks while working.
On 12/19/23 at 1:08 PM, V2 (Director of Nursing) said that after a resident tested positive on 11/13/23, they tested all of the residents twice in that week and then after that, they have been testing them if they develop any COVID symptoms but have not done any routine testing on them besides the first week. V2 said that she is not sure if the staff were being tested on a routine basis.
On 12/19/23 at 1:45 PM, V14 (Licensed Practical Nurse) said that she tested for COVID-19 the other day due to cold like symptoms and it was negative but besides that she has not done any routine testing during the current COVID-19 outbreak. V14 said that in the past (many months ago) they had to test on a routine basis but she has not with this current outbreak.
On 12/19/23 at 3:54 PM, V15 and V16 (Activity Aides) both said that they work with residents throughout the facility. V15 and V16 both said that they have not tested positive for COVID-19 within the last three months. V15 and V16 both said that their boss told them last week that they had to test for COVID-19 and did a test but that is they only test that they have done recently. V15 and V16 both said that they have not had any additional COVID-19 testing done in months.
On 12/19/23 at 12:23 PM, V18 (Local Health Department Infection Control Coordinator) said that once a facility identifies a positive resident or staff member, they should be testing all residents and staff every 3-5 days until they have had no new cases for 14 days if the outbreak is facility wide.
The facility was unable to provide evidence that all residents and staff that were not COVID positive after the initial testing were tested every 3-7 days after a facility wide outbreak was identified.
The facility's undated Coronavirus (COVID-19) Testing Plan and Response Strategy shows, Outbreak Scenario: Facility wide testing of employees and residents will take place if deemed appropriate by facility administration or facility medical director or as directed by [Local Health Department] or the [State Health Department] If one or more resident or employee tests positive for COVID-19, contact tracing will be conducted. Baseline testing for possibly exposed persons will be conducted. Monitoring and testing of residents and employees will continue until no new resident or employee cases are identified for a period of atleast 14 days since the most recent positive result, then weekly testing, or as mandated by local health department or [State Health Department] per positivity rate or facilities discretion after contact tracing is done.
3. R89's Physician Orders Sheet dated December 1, 2023-December 31, 2023 shows she was admitted to the facility on [DATE] with diagnoses including weakness, urinary tract infection, polyosteoarthritis, congestive heart failure.
On December 19, 2023 at 10:06 AM, V5 CNA (Certified Nursing Assistant) provided incontinence care to R89. R89 had a large amount of soft stool in her incontinence brief. V5 wiped R89's front peri area of the stool, then touched the resident's body to help her turn, touched the resident's dresser drawer, and R89's clean incontinence brief. V5 then wiped R89's buttocks area of the large stool and place the clean incontinence brief under R89. V5 did not change her gloves or perform hand hygiene prior to touching clean surfaces.
On December 20, 2023 at 9:03 AM, V12 CNA said gloves should be changed when going from dirty to clean items so that germs do not get transferred.
4. R32's Physician Orders Sheet dated December 1, 2023-December 31, 2023 shows R32 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, metabolic encephalopathy, and acute kidney failure. An order was entered on October 12, 2023 for maintain contact isolation precautions for ESBL (Extended spectrum beta-lactamases-Escherichia Coli) in urine every shift. An order was entered on December 6, 2023 for Macrodantin 50 mg once daily. (antibiotic used to treat urinary tract infections).
R32's Care Plan Effective September 7, 2023 shows resident is on contact isolation precautions related to ESBL in urine. Protective personal equipment to be worn only if splash of bodily fluids are anticipated.
On December 18, 2023 at 9:28 AM, there was a sign on R32's door that showed contact isolation: gloves and gown required.
On December 19, 2023 at 9:41 AM, V4 CNA walked out of R32's room. V4 did not know why R32 was on isolation but had to find out from the nurse. V4 said that R32 was on contact isolation for ESBL in her urine. V4 said she had just helped R32 to use the restroom and R32 urinated in the toilet. V4 said R32 can be incontinent at times. R32 said staff do not wear gowns when they toilet her. V4 said that staff only wear gloves to take care of R32. V4 said, We just wear gloves, she's only on contact isolation.
On December 20,2023 at 9:03 AM, V12 CNA said masks, shoe covers, goggles, gloves, down, and head cover should be worn when a resident is on contact isolation so that the bacteria does not stick to her and give the bacteria to another resident.
On December 20, 2023 at 9:32 AM, V3 CNA Supervisor said when residents are on contact isolation, Staff do not have to gown up unless we anticipate spitting projectiles, normally they just wear gloves. We never worn gowns unless we anticipate splashing of urine and we don't wear gowns when taking residents to the bathroom.
The facility's Contact Isolation Policy dated August 6, 2023 does not include information on wearing gowns during resident care.
5. The facility's Infection Log for December 2023 shows R90 is on droplet isolation precautions due to respiratory illness symptoms.
On December 28, 2023 at 11:30 AM, there was a sign on R90's door that reflected Droplet Isolation. Upon donning PPE, V4 CNA said, I'm not going to put a N95 mask on because I already have one on. V4 did not place an extra barrier over her current N95 mask. V4 CNA went into R90's room to attempt to toilet her. V4 stood next to R90's bed while R90 was lying in it and asked R90 if she needed to be toileted. V4 was less than three feet away from R90. R90 was actively coughing while V4 was interacting with R90. V4 did not change her N95 masks upon exiting R90's room and prior to interacting with other residents.
On December 20, 2023 at 9:03 AM, V12 CNA said N95 masks should be changed when exiting a resident's room when they are on droplet isolation.
2. The facility's December 2023 Infection Log showed R21 was on droplet isolation precautions.
On 12/18/23 at 8:40 AM, there was a droplet isolation sign on the door of R21's room. The sign indicated staff were to wear the following personal protective equipment (PPE): mask, gown, and gloves.
On 12/18/23 at 8:48 AM, V10 (Certified Nursing Assistant- CNA) entered R21's room to deliver a meal tray and set R21 up to eat. The only PPE V10 had on when entering R21's room was a surgical mask. V10 came within 3 feet of R21 when setting up R21 to eat. R21 did not have a mask on.
On 12/18/23 at 2:21 PM, V11 (CNA) entered R21's room to get vital signs. The only PPE V11 had on was a N95 mask. R21 did not have a mask on.
On 12/18/23 at 2:36 PM, V8 (Infection Control Nurse) said staff should wear the following PPE when entering R21's room: N95 mask with a surgical mask covering the N95 mask, isolation gown, and gloves.
The facility's Droplet Precaution policy showed gowns should be used whenever giving direct care to the resident or being within three feet unless the resident is masked.