**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, for 1 of 12 sampled residents, that the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident who was identified to have a pressure ulcer upon admission did not receive treatment and services for wound care. Resident identifier: 121. Findings include: Resident 121 was admitted to the facility on [DATE], with diagnoses which included upper gastrointestinal bleed, hemorrhagic shock, generalized weakness, severe anemia, protein malnutrition, acute hypoxic respiratory failure, hypernatremia, hypokalemia, Parkinson's disease, heart failure, and hypotension. Resident 121's medical record was reviewed from 4/8/24 through 4/10/24. The Brief Interview for Mental Status (BIMS) dated 4/6/24 at 8:22 PM, indicated resident 121 had a BIMS score of 11 which indicated a cognitive level of Moderately Impaired. The admission Nursing Observation form dated 4/6/24 at 5:04 PM, indicated a skin alteration was identified. A Braden Risk Score of 18.0, which indicated a level of Low Risk. The admission Nursing Observation form further indicated that the Care Plan included: 1. Resident has been identified: At risk for developing pressure ulcers 2. With current pressure ulcer(s) 3. Related to: Impaired Mobility The care plan indicated the degree of the resident's physical activity was, Walks Occasionally- Walks occasionally during day but for very short distances, with/without assist. Spends majority of each shift in bed or chair. It indicated that the resident's ability to change and control body position was, Slightly Limited- Makes frequent, though slight, changes in body or extremity position independently. It further indicated that the resident's usual food intake pattern was, Probably Inadequate- Rarely eats a complete meal and generally eats only about ½ (half) of food offered. Protein intake includes only 3 services of meat or dairy products per day. Occasionally will take a dietary supplement- OR- Receives less than optimum amount of liquid diet or tube feeding. The care plan dated 4/6/24 indicated, the problem, Risk of/or actual alteration in skin integrity; with the goal, Decreased risk of developing (additional) areas of altered skin integrity. It further indicated the following approaches, TREATMENTS Barrier Ointment Asisst/Prompt Turn Q [every] 2 hrs (hours) Dressing per MD (medical doctor) Order .WOUND TYPE: Pressure ulcer .WOUND SITE bilat. buttocks. An Admit Skin assessment dated [DATE], indicated resident 121 had, Non blanching discoloration and an open area identified on the coccyx region of the back of a drawn body outline. A physician order dated 4/6/24 at 8:38 PM, indicated a Wound Specialist Referral had been made. An Alert Charting: New Admits progress note dated 4/7/24 at 12:39 AM indicated, .Nursing staff assisted the resident to bed, after a new drsg [dressing] was placed on his coccyx area . On 4/9/24 at 11:15 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that when a resident was admitted the nurse would do an initial assessment which would include a skin assessment of the whole body and any wounds. RN 1 stated that if a wound was identified he would notify the physician and get orders to treat it. On 4/10/24 at 10:30 AM, an interview was conducted with RN 2. RN 2 stated that resident 121 had no skin breakdown and had no physician orders that indicated he had any skin breakdown. RN 2 stated that a thorough skin check should have been completed on Sunday and that the wound care team evaluated residents every Tuesday. On 4/10/24 at 11:12 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 121 had some redness on his buttocks and knew the nurses had been, watching it. CNA 1 further stated that he did not have a dressing on the reddened area. On 4/10/24 at 11:16 AM, an interview was conducted with the Director of Nursing (DON). The DON stated resident 121 did not have a pressure injury and that the Alert Charting: New Admits progress note dated 4/7/24 at 12:39 was documented under the wrong resident. The DON reviewed resident 121's electronic medical record during interview and discovered the Admit Skin assessment dated [DATE], indicated resident 121 did have documented skin alterations. The DON stated she needed to do a skin assessment on resident 121. On 4/10/24 at 11:34 AM, a skin assessment of resident 121, provided by the DON, was observed. Resident 121 was laying on his back in his bed. The DON assisted the resident to pull down his brief and roll onto his right side to expose his buttocks, there was no dressing observed. There was redness and areas of scar-like tissue noted to the left and right side of the buttocks, which the DON described as possible healed pressure injuries. The DON pressed on the pink tissue and stated the skin was pink and blanchable. The DON stated that resident 121 could have used a pressure reduction dressing to his right and left buttocks and that she would take a picture and send it to the wound assessment team. The DON stated the wound team would measure and diagnose the wounds and then they would tell us what more they want us to do to treat. The DON placed 2 4 x (by) 4 Optiform Gentle EX dressings, one on each side of the left and right buttocks. On 4/10/24 at 12:39 PM, a follow up interview was conducted with the DON. The DON stated that the admission nurse should do a full skin assessment when a resident was admitted and if the resident had a possible pressure injury, the nurse should take pictures and notify the wound care team that day. The DON further stated that having the order for a Wound Specialist Referral would not trigger the wound care team to evaluate the resident and that the facility would have to notify them directly. The DON stated resident 121 should have been evaluated by the wound care team on Tuesday, April 9th.

Based on observation, interview, and record review, it was determined that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food safety. Specifically, staff were observed to not wear hair and beard coverings in the kitchen. Findings included: On 4/8/24 the following observation was made of the kitchen: At 8:10 AM, the Dietary Manager (DM) was observed to not have a hair net in place while in the kitchen, the hair net was put in place when this surveyor entered the kitchen. On 4/9/24 the following observations were made in the kitchen: At 10:22 AM, an observation was made of two Maintenance Workers (MW) performing care on the ice machine in the kitchen. MW (1) was observed to have a beard that extended approximately 2 inches below his jawline. MW (1) was observed to wear a baseball cap on his head, no beard net was observed to be in place. At 10:44 AM, an observation was made of MW (1). MW (1) was observed in the kitchen near the ice machine, went outside and came back into the kitchen. MW (1) did not have a beard net in place. At 11:05 AM, an observation was made of MW (1). MW (1) walked into the kitchen and back out of the kitchen past uncovered desserts with no beard net in place. At 11:48 AM, an observation was made of MW (1). MW (1) entered the kitchen with no beard net in place. At 12:01 PM, an observation was made of MW (1). MW (1) walked past the food tray line to exit the kitchen with no beard net in place. Uncovered food was observed on the food tray line. At 12:05 PM an observation was made of MW (1). MW (1) was observed to return to the kitchen and walk past the food tray line that had uncovered food, with no beard net in place. At 1:19 PM an observation was made as MW (1). MW (1) entered the kitchen from an outside door and walking through kitchen to dining room with no beard net in place. At 1:23 PM an observation was made as MW (1). MW (1) entered the kitchen from the dining room, walked through the kitchen and exited through an outside door near the ice machine. At 2:00 PM an observation was made of a local delivery person walked through the kitchen without a hair net in place or hat on his head. At 2:03 PM an observation was made of MW (1). MW (1) was observed to be in the kitchen with no beard net in place as he worked on the ice machine. At 2:04 PM an observation was made of the DM. The DM entered the kitchen from the dining room with no hair net in place. The DM was observed to walk through the kitchen and enter her office at the rear of the kitchen. On 4/10/24 at 8:38 AM, an interview was conducted with the DM. The DM stated everyone knows that the hairnets are available at the corner of the dining room, before entering the kitchen. The DM stated that staff sometimes come to get ice from the ice machine located in the kitchen and they need to wear a hair net. The DM stated all workers, even those contracted, are expected to wear hair protection. The DM stated she would have expected those who worked on the ice machine yesterday to wear the nets. The DM stated the delivery person was not supposed to take anything through the kitchen. The DM stated there were no hair nets supplied by the back door. The DM stated she expected everyone who entered the kitchen to wear a net to cover their hair or beard. On 4/10/24 at 10:10 AM, an interview was conducted with the Registered Dietician (RD). The RD stated all staff, whether in house or contracted, should wear hair nets if entering the kitchen from any door.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review it was determined, for 1 of 10 sample residents, that the facility did not develop and implement a comprehensive person centered care plan of each resident that included measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. Specifically, one resident with family issues did not have a comprehensive care plan for a safe discharge. Resident identifiers: 4. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses which included hypertension, arthritis, lumbar spinal stenosis, orthopedic aftercare and chronic obstructive pulmonary disease. On 1/21/20 resident 4's medical record was reviewed. Social Service progress notes for resident 4 revealed the following entry: a. Social Services Progress Note: (1/8/20 16:30-17:30) LCSW for family dynamic issues impeding d/c (discharge) plans. Pt (patient) seems to have full capacity to make her own decisions but dtr (daughter) [Name of Daughter] says she has some dementia by phone. Pt gives little information about family dynamic issues but doesn't elaborate and says, I'll be good and I'll keep quiet. She puts her hands underneath her seat as she says this. Pt confirms there is no abuse. According to dtr [Name of Daughter], pt claimed abuse in the past to other family members. They considered reporting it but didn't follow through, as they ended up recognizing mutual dynamic issues between pt and dtr. APS (Adult Protective Services) has not been involved. Pt says, No one talks to me. She says she is isolated. Pt is widowed 14 yrs after marriage of 52 yrs. She has 6 cdn (children) and 1 adopted. According to dtr {Name of daughter] by phone, No one wants anything to do with her. Pt says a son recently came to see her in rehab, for the first time in 2 yrs. Pt manages her own finances. She doesn't have a POA (Power of Attorney) and doesn't know who she would name as POA. Her total income with SSI (Social Security Income), retirement and payout for an injury is about $2000/m (month). Dtr thinks pt has about $30,000 in savings/investments but doesn't know for sure. Pt owns a car. Pt's name is on the title to the house she and dtr live in. Pt has about $3,000 invested. Dtr and her husband pay the mortgage of $1000/m and she says they have about $30,000 invested. Dtr lives there with her husband and 5 boys under the age of 16. Dtr says she is trapped. She says pt is difficult to live with. Pt isolates and doesn't join them for meals. She triangulates and pits members of the house against each other. Dtr says she can't live this way anymore. She says this is the second time she's been stuck in a living arrangement with pt. She doesn't know what to do and wants pt to go to ALF (Assisted Living Facility). Pt went to [Assisted Living] ALF before, for two weeks. They were working on getting pt VA (Veterans Administration) Aid and Attendance pension to cover some of the cost. Pt ended up convincing dtr to come pick her up and take her home. Pt didn't pay for her stay and owes [Assisted Living]. Pt said it was the worst 2 weeks of her life. Pt said dtr made her life miserable at ALF and now she's going to make dtr's life miserable (per dtr's report by phone). She says pt is succeeding in making her life miserable. Dtr is tearful. Pt says she will not go to ALF and isn't interested in talking about options. LCSW (Licensed Clinical Social Worker) explained pt cannot be persuaded or forced to go to ALF. Her name is on the title to the home and she can return. She cannot go to ALF without payment. Dtr will have to come pick her up for d/c. Dtr says she considers moving out and taking a loss financially. LCSW expressed sympathy. Gathered information and facilitated processing. Explored community resource options. Pt was getting [NAME] (meals on wheels) 5x/w before. She will continue to get them once she returns home. Collaborated with [Home Health Marketing Director] in marketing and [Administrator] in administration. Date/Time: 01/12/2020 17:53 (5:53 PM). No documentation could be located in the medical record to show that facility staff had created a comprehensive care plan for a safe discharge for resident 4. On 1/22/20 at 12:58 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they would like to have a safe discharge for resident 4 when she went home. The facility DON stated that he did not know why there was not a comprehensive care plan regarding resident 4's upcoming discharge on Saturday. On 1/22/20 at 1:03 PM, an telephone interview was conducted with the facility LCSW. The LCSW stated that she had not created a comprehensive care plan for a safe discharge for resident 4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, for 1 of 10 sample residents, that the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, one resident who had a difficult home situation, did not receive follow up discharge planning to assist with a safe discharge. Resident identifier: 4. Findings include: Resident 4 was admitted to the facility on [DATE] with diagnoses which included hypertension, arthritis, lumbar spinal stenosis, orthopedic aftercare and chronic obstructive pulmonary disease. On 1/21/20 resident 4's medical record was reviewed. Social Service progress notes for resident 4 revealed the following entry: a. Social Services Progress Note: (1/8/20 16:30-17:30) LCSW for family dynamic issues impeding d/c (discharge) plans. Pt (patient) seems to have full capacity to make her own decisions but dtr (daughter) [Name of Daughter] says she has some dementia by phone. Pt gives little information about family dynamic issues but doesn't elaborate and says, I'll be good and I'll keep quiet. She puts her hands underneath her seat as she says this. Pt confirms there is no abuse. According to dtr [Name of Daughter], pt claimed abuse in the past to other family members. They considered reporting it but didn't follow through, as they ended up recognizing mutual dynamic issues between pt and dtr. APS (Adult Protective Services) has not been involved. Pt says, No one talks to me. She says she is isolated. Pt is widowed 14 yrs after marriage of 52 yrs. She has 6 cdn (children) and 1 adopted. According to dtr {Name of daughter] by phone, No one wants anything to do with her. Pt says a son recently came to see her in rehab, for the first time in 2 yrs. Pt manages her own finances. She doesn't have a POA (Power of Attorney) and doesn't know who she would name as POA. Her total income with SSI (Social Security Income), retirement and payout for an injury is about $2000/m (month). Dtr thinks pt has about $30,000 in savings/investments but doesn't know for sure. Pt owns a car. Pt's name is on the title to the house she and dtr live in. Pt has about $3,000 invested. Dtr and her husband pay the mortgage of $1000/m and she says they have about $30,000 invested. Dtr lives there with her husband and 5 boys under the age of 16. Dtr says she is trapped. She says pt is difficult to live with. Pt isolates and doesn't join them for meals. She triangulates and pits members of the house against each other. Dtr says she can't live this way anymore. She says this is the second time she's been stuck in a living arrangement with pt. She doesn't know what to do and wants pt to go to ALF (Assisted Living Facility). Pt went to [Assisted Living] ALF before, for two weeks. They were working on getting pt VA (Veterans Administration) Aid and Attendance pension to cover some of the cost. Pt ended up convincing dtr to come pick her up and take her home. Pt didn't pay for her stay and owes [Assisted Living]. Pt said it was the worst 2 weeks of her life. Pt said dtr made her life miserable at ALF and now she's going to make dtr's life miserable (per dtr's report by phone). She says pt is succeeding in making her life miserable. Dtr is tearful. Pt says she will not go to ALF and isn't interested in talking about options. LCSW (Licensed Clinical Social Worker) explained pt cannot be persuaded or forced to go to ALF. Her name is on the title to the home and she can return. She cannot go to ALF without payment. Dtr will have to come pick her up for d/c. Dtr says she considers moving out and taking a loss financially. LCSW expressed sympathy. Gathered information and facilitated processing. Explored community resource options. Pt was getting [NAME] (meals on wheels) 5x/w before. She will continue to get them once she returns home. Collaborated with [Home Health Marketing Director] in marketing and [Administrator] in administration. Date/Time: 01/12/2020 17:53 (5:53 PM). No documentation could be located in the medical record to show that facility staff had followed up on the interview, had reported the interview to APS, nor that outside resources had been explored for a safe discharge for resident 4. On 1/22/20 at 12:47 PM, an interview was conducted with resident 4. Resident 4 stated that she had her room which she stayed in and had her meals on wheels that she would have reinstated. Resident 4 stated that she had her car if she needed to go somewhere. Resident 4 stated that she cannot afford assisted living and wanted to go home. Resident 4 stated that she had issues with all of her kids, and that you'd have to know the whole situation. Resident 4 stated that it has taken 40 years to build the walls between them. On 1/22/20 at 12:58 PM, an interview was conducted with the facility Director of Nursing (DON). The facility DON stated that they had been told by the LCSW that the patient was more of the instigator in the family dynamics rather than the victim. The facility DON stated that they would like to have a safe discharge for resident 4 when she went home. The facility DON stated that he did not know why the conversation regarding past abuse had not been called into APS. The facility DON stated that he did not know if outside resources had been called to assist resident 4 is having a safe discharge to home. On 1/22/20 at 1:03 PM, an telephone interview was conducted with the facility LCSW. The LCSW stated that she had tried other avenues when talking to resident 4 such as an assisted living facility but that resident 4 had declined. The LCSW stated that resident 4's name was on the title of the home along with the son in law, and that the daughter was feeling trapped because she pays the mortgage. The LCSW stated that she did not notify APS about the claim of abuse by resident 4's daughter because resident 4 triangulates the family and would pit the young children against each other, causing fights between them thus causing a tense atmosphere. The LCSW stated that she had advocated for resident 4 to be able to go back home. The LCSW stated that she could call aging services since resident 4 had meals on wheels and see if there could be any kind of case management. The LCSW stated that she understood the possibility of neglect or abuse at the home and stated that I guess I didn't look that far into getting outside resources because the resident is resistant. The LCSW stated that she was nervous with resident 4 because I don't know what to do. Stated that she would try to get some counseling services for resident 4.

Based on observation and interviews it was determined that the facility did not ensure safe and secure storage of drugs and biologicals in accordance with accepted best practices; nor did they include the appropriate cautionary instructions, and the expiration/discard date on the medication. Specifically, glucose control solutions in the facility did not have discard dates written on the label and were not correctly stored. Findings include: 1. On 1/21/20 at approximately 3:36 PM, an observation was made of the medication cart. The glucose control solution was found to be in a box with a manufacturer's expiration date of 1/15/20, with no open date noted on the box. The Normal glucose control solution bottle had an expiration date of 5/31/2020, while the high solution control solution bottle had an expiration date of 3/20/2020. Neither the normal or high solution control solution had a discard date written on the line that was printed on the label next to the word discard date. [Note: the glucose control solution was used to test accurate functioning of the glucose meter and test strips.] On 1/21/20 at 3:40 PM, an interview was conducted with Registered Nurse RN 1. RN 1 was not sure of the policy and procedure on the normal and high glucose solution. A review of the glucose control solution manufacturer manual found at https://www.medline.com/media/catalog/Docs/MKT/LIT715R_MAN_EvenCare%20ProView%20In-Serv.pdf revealed important instructions for use on page 8 of the manual . Control solutions are good three months after opening date or until the last day of the month of expiration, whichever comes first. On 1/22/20 at approximately 9:00 AM; an interview with Director of Nursing (DON) and Corporate Nurse (CN) was conducted. The DON and the CN verified the different expiration dates on the normal glucose solution, high glucose solution, and on the box. The DON and CN stated they were not sure if the glucose solutions needed a discard date and what the discard date should be. The DON and the CN stated that they were not sure why the manufacturer's put a discard date and an expiration date on the solution if a discard date was not needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, for 4 of 10 sample residents, that the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, facility did not follow respiratory therapy infection control by changing the oxygen cannula's and tubing weekly. Findings include: a. On 1/21/20 at 12:07 PM it was observed that room [ROOM NUMBER]'s portable oxygen tanks nasal cannula was not changed on 1/16/20 and the wall nasal cannula was dated 1/17/20. b. On 1/21/20 at 12:10 PM it was observed that room [ROOM NUMBER]'s portable oxygen tanks nasal cannula was not changed on 1/16/20. c. On 1/21/20 at 12:15 PM it was observed that room [ROOM NUMBER]'s portable oxygen tanks nasal cannula was not changed on 1/16/20 and the wall nasal cannula was dated 1/10/20. d. On 1/21/20 at 12:20 PM it was observed that room [ROOM NUMBER]'s wall nasal cannula had no date on it. Not sure how long the nasal cannula had been in use. On 1/21/20 at 12:03 AM; an interview was conducted with Certified Nurse Assistant (CNA) 1. CNA 1 stated that all nasal cannula's were changed Saturday evenings. On 1/22/20 at 10:29 AM; an interview was conducted with the Director of Nursing (DON). The DON was asked about a policy for nasal cannula changes. The DON stated they had a policy and retrieved the policy. On 1/22/200 at 10:45 AM; a record review of the policy and procedures for respiratory therapy infection control was conducted. In NS Respiratory 2018 step 7 of the policy was to Change the oxygen cannula and tubing weekly or if contaminated. On 1/22/20 at 11:02 AM; an interview was conducted with the DON and Corporate Nurse (CN). The DON and the CN stated that nasal canals were changed on Saturday evening shift. On 1/22/20 at 12:27 PM; an interview was conducted with CNA 1 and CNA 2. CNA 1 and CNA 2 stated that they did not know why the nasal cannula's had not been changed and replaced with new nasal cannula's.