The Terraces Of Phoenix

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure allegations of sexual abuse for two residents (#23 and #12) by another resident (#45) was reported immediately to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. The deficient practice could result in the potential harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm.

Findings include:

-Resident #12 admitted on January 26, 2024 with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety.

The quarterly MDS assessment dated April 30, 2024 revealed a Brief Interview for Mental Status (BIMS) score 15 which indicated the resident had intact cognition.

The undated active care plan revealed that the resident was at risk for problematic behavior i.e. history of fabricating false accusations against staff that attempt to give directions on ADLs (activities of daily living), medications, diabetes control and management. The goal was that the resident will accept re-direction when making false accusations. Interventions included to identify stressful times of the day, schedule activities and tasks for other times, help the resident to cope using past successful coping mechanisms and praise/reward resident for demonstrating appropriate interactions with staff and others.

The undated active care plan also included that the resident had actual or suspected history of personal trauma, was abused by a babysitter at the age of 3 and had associated behaviors of mis-trust for other caregivers. The goal was that the resident will maintain psychosocial well-being. Interventions included to offer reassurance of safety and trust and restore a sense of control by honoring the resident's choices.

The nursing progress note dated July 26, 2024 included that the resident reported to the certified nursing assistant (CNA) that she had a bad day because something happened to her today that "brought back past memories." Per the documentation, the resident had "no unusual events reported other than officers here to visit for statement due to accusation regarding a staff member on another date and time." The documentation did not include whether the allegation was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement.

A late entry alert note dated August 1, 2024 included that the resident was seen by investigators before lunch; and that, the investigators went to speak to the Administrator.

There was no evidence found in the clinical record that this incident was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement until August 9, 2024.

Review of the SA complaint tracking system included a facility self-report dated August 9, 2024. The self-report revealed that during their investigation of another incident, the facility found in the clinical record that on July 24, 2024 resident #45 touched the leg of resident #12.

In an interview with resident #12 conducted on August 9, 2024 at 4:45 p.m., the resident stated that resident #45 would come up to her often up to twice daily and rub her knee and thigh; and that, the touch was very unwanted. The resident also stated that she had reported this to several nurses and certified nursing assistants (CNAs) who were often were present in the area when resident #45 touches her. The resident said that when this happens, the nurses and CNA who were present would laugh and think that it was funny, and would tell Resident #45 not to touch her. The resident stated that she can escape into her room which is her safe place because resident #45 does not enter her room. However, the resident stated that resident #45 would sit right outside her door and stare at her specifically when she changes clothing.

In an interview with a CNA (staff #6) conducted on August 9, 2024 at approximately 5:00 p.m., the CNA state that on Monday, August 5, 2024, she witnessed resident #45 rubbing the arm and back of resident #12 who had not in any way invited the touch. The CNA stated that she told resident #45 that he could not do that and then she went to report the incident to the RN (staff #5)

-Resident #23 admitted on March 31, 2023 with diagnoses of dementia and depression.

The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to pleasurable events each day. Intervention included to engage the resident's senses with pleasant smells.

The quarterly Minimum Data Set (MDS) assessment dated July 13, 2024 revealed that staff assessment that the resident had severe cognitive impairment.

A health status note dated August 7, 2024 included that the resident's Power of Attorney (POA) was informed of an inappropriate behavior displayed by a male resident to the resident #23; and that, the male resident was witnessed to touch the resident's arm/back.

An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that he was aware of the incident regarding resident #45 touching resident #23; and that, he was not part of the investigation. The SSD said that resident #23 was non-verbal and her eyes would track you when you are talking to her but cannot indicate a "yes" or "no" response.

-Resident #45 was admitted on February 15, 2023 with diagnosis of dementia.

The MDS assessment dated June 28, 2024 included a BIMS score of 7 indicating the resident had severe cognitive impairment.

The undated care plan revealed the resident had a behavior problem of inappropriate touching of a female resident related to dementia. The goal included that the resident will have no evidence of behavior problem of inappropriately touching. Interventions included 1:1 monitoring x 2 weeks, document his behavior every shift, report any sexual behavior to nurse and redirect as needed.

A progress note dated July 24, 2024 and written by a registered nurse (RN/staff #5) revealed that the resident touched a female resident on the leg; and that, it was unwanted. Per the documentation, the resident was redirected. The documentation did no include whether the incident was reported to the the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement.

There was no evidence found in the clinical record that this incident was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement.

There was also no evidence found in the clinical record that interventions were put in place to prevent the reoccurrence of resident #45 inappropriately touching or sexual advances to other female residents.

A health status note written by a registered nurse (RN/staff #5) dated August 7, 2024 revealed that the resident was observed multiple times groping the breasts of a female resident. Per the documentation, staff explained to the resident the "wrongful behavior", was redirected and the resident showed "no signs of understanding."

Another health status note dated August 7, 2024 included that the resident was on alert charting related to inappropriate activities of wanting to touch other residents; and that, the resident was "monitored hourly regarding his whereabouts."

A behavior note dated August 7, 2024 included that the physician was notified regarding the resident's inappropriate behavior.

Despite the documentation that a resident was observed multiple times groping the breasts of a female resident, the facility self-report received on August 7, 2024 revealed that the resident was seen touching another resident; an

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of two residents (#12 and #23) to be free from sexual abuse by another resident (#45). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. The census was 43.

Findings include:

-Resident #23 admitted on March 31, 2023 with diagnoses of dementia and depression.

The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to pleasurable events each day. Intervention included to engage the resident's senses with pleasant smells.

The quarterly Minimum Data Set (MDS) assessment dated July 13, 2024 revealed that staff assessment that the resident had severe cognitive impairment.

A health status note dated August 7, 2024 included that the resident's Power of Attorney (POA) was informed of an inappropriate behavior displayed by a male resident to the resident #23; and that, the male resident was witnessed to touch the resident's arm/back.

An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that he was aware of the incident regarding resident #45 touching resident #23; and that, he was not part of the investigation. The SSD said that resident #23 was non-verbal and her eyes would track you when you are talking to her but cannot indicate a "yes" or "no" response.

-Resident #12 admitted on January 26, 2024 with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety.

The quarterly MDS assessment dated April 30, 2024 revealed a Brief Interview for Mental Status (BIMS) score 15 which indicated the resident had intact cognition.

The undated active care plan revealed that the resident was at risk for problematic behavior i.e. history of fabricating false accusations against staff that attempt to give directions on ADLs (activities of daily living), medications, diabetes control and management. The goal was that the resident will accept re-direction when making false accusations. Interventions included to identify stressful times of the day, schedule activities and tasks for other times, help the resident to cope using past successful coping mechanisms and praise/reward resident for demonstrating appropriate interactions with staff and others.

The undated active care plan also included that the resident had actual or suspected history of personal trauma, was abused by a babysitter at the age of 3 and had associated behaviors of mis-trust for other caregivers. The goal was that the resident will maintain psychosocial well-being. Interventions included to offer reassurance of safety and trust and restore a sense of control by honoring the resident's choices.

The nursing progress note dated July 26, 2024 included that the resident reported to the certified nursing assistant (CNA) that she had a bad day because something happened to her today that "brought back past memories." Per the documentation, the resident had "no unusual events reported other than officers here to visit for statement due to accusation regarding a staff member on another date and time."

A late entry alert note dated August 1, 2024 included that the resident was seen by investigators before lunch; and that, the investigators went to speak to the Administrator.

In an interview with resident #12 conducted on August 9, 2024 at 4:45 p.m., the resident stated that resident #45 would come up to her often up to twice daily and rub her knee and thigh; and that, the touch was very unwanted. The resident also stated that she had reported this to several nurses and certified nursing assistants (CNAs) who were often were present in the area when resident #45 touches her. The resident said that when this happens, the nurses and CNA who were present would laugh and think that it was funny, and would tell Resident #45 not to touch her. The resident stated that she can escape into her room which is her safe place because resident #45 does not enter her room. However, the resident stated that resident #45 would sit right outside her door and stare at her specifically when she changes clothing.

An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that the administrator was the one investigating the incident on resident #45 patting another female resident on the shoulder.

In an interview with a CNA (staff #6) conducted on August 9, 2024 at approximately 5:00 p.m., the CNA state that on Monday, August 5, 2024, she witnessed resident #45 rubbing the arm and back of resident #12 who had not in any way invited the touch. The CNA stated that she told resident #45 that he could not do that and then she went to report the incident to the RN (staff #5)

-Resident #45 was admitted on February 15, 2023 with diagnosis of dementia.

The MDS assessment dated June 28, 2024 included a BIMS score of 7 indicating the resident had severe cognitive impairment.

The undated care plan revealed the resident had a behavior problem of inappropriate touching of a female resident related to dementia. The goal included that the resident will have no evidence of behavior problem of inappropriately touching. Interventions included 1:1 monitoring x 2 weeks, document his behavior every shift, report any sexual behavior to nurse and redirect as needed.

A progress note dated July 24, 2024 and written by a registered nurse (RN/staff #5) revealed that the resident touched a female resident on the leg; and that, it was unwanted. Per the documentation, the resident was redirected.

There was also no evidence found in the clinical record that interventions were put in place to prevent the reoccurrence of resident #45 inappropriately touching or sexual advances to other female residents .

A health status note dated August 1, 2024 included that the resident was sexually explicit, was masturbating in his bed and was asking "where's that girl?" referring to the CNA.

A health status note written by a registered nurse (RN/staff #5) dated August 7, 2024 revealed that the resident was observed multiple times groping the breasts of a female resident. Per the documentation, staff explained to the resident the "wrongful behavior", was redirected and the resident showed "no signs of understanding."

Another health status note dated August 7, 2024 included that the resident was on alert charting related to inappropriate activities of wanting to touch other residents; and that, the resident was "monitored hourly regarding his whereabouts."

A behavior note dated August 7, 2024 included that the physician was notified regarding the resident's inappropriate behavior.

Despite the documentation that a resident was observed multiple times groping the breasts of a female resident, the facility self-report received on August 7, 2024 revealed that the resident was seen touching another resident; and that, the facility was "investigating specifically the location of resident touching."

A written statement from the RN (staff #5) dated August 7, 2024 included that the RN was at his medication cart on August 6, 2024 at approximately 5:30 p.m., he saw resident #45 was trying to touch resident #23; and that, the RN was able to intervene and redirect resident #45 before resident #45 could touch resident #23. Per the documentation, the RN assumed that resident #45 was going to grope the breasts of resident #23 because the RN had seen resident #45 was reaching towards the breasts of resident #23. Further, the documentation included that resident #45 attem

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to ensure allegations of sexual abuse for two residents (#23 and #12) by another resident (#45) was reported immediately to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement. The deficient practice could result in the potential harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 43.

Findings include:

On August 9, 2024 at 5:34 p.m., a condition of IJ was identified. The administrator was informed of the facility's failure to ensure residents were free from sexual abuse by a resident was found.

The administrator presented the removal plan on August 9, 2024 at 8:23 p.m. The administrator was informed that the removal plan was not acceptable and failed to include any assessment completed for resident #12 and #23; until when will resident #45 be placed on 1:1 supervision; other interventions put in place to prevent inappropriate behaviors for resident #45; when the in-service training was started and expected to be completed for all staff; identify the staff that would complete the in-service training; and, actions the facility will take if a staff did not complete the required in-service/training.

A revised removal plan was received on August 9, 2024 at 9:25 p.m. and was not accepted because it failed to include when the in-service training was started for all staff including staff that were on leave; how the facility will monitor resident #45 for inappropriate behaviors; until when will resident #45 be placed on 1:1 supervision; other interventions put in place to prevent inappropriate behaviors for resident #45; what actions will be taken for staff who documented the incident but did not report the allegation of abuse; and, how often and what kind of audits or monitoring will be done to identify any potential abuse.

Another revised removal plan was presented by the administrator on August 9, 2024 at 10:31 p.m. the administrator was informed that the removal plan was not accepted and failed to include: what actions will be taken for staff who documented the incident but did not report the allegation of abuse; how the facility will monitor resident #45 for inappropriate behaviors; and, how often and what kind of audits or monitoring will be done to identify any potential abuse.

On August 10, 2024 at 8:33 a.m., the administrator presented a revised removal plan that was accepted at 8:47 a.m. The accepted removal plan included:
-Medical and Psychiatric Assessment completed for resident #12 and #23;
-In-service training on abuse was started and expected to be completed for all staff including staff that were on leave;
-Actions the facility will take if a staff did not complete the required in-service/training;
-Actions taken for staff who documented the incident but did not report the allegation of abuse;
-How the facility will monitor resident #45 for inappropriate behaviors, until when will resident #45 be placed on 1:1 supervision and other interventions put in place to prevent inappropriate behaviors for resident #45; and,
-How often and what kind of audits or monitoring will be done to identify any potential abuse.

On August 10, 2024 at 12:28 p.m., the condition of IJ was removed after multiple observations were conducted of the facility implementing their removal plan which included resident and staff interviews, personnel record review, in-service training of staff and review of documentation provided by the facility.

-Resident #12 admitted on January 26, 2024 with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety.

The quarterly MDS assessment dated April 30, 2024 revealed a Brief Interview for Mental Status (BIMS) score 15 which indicated the resident had intact cognition.

The undated active care plan revealed that the resident was at risk for problematic behavior i.e. history of fabricating false accusations against staff that attempt to give directions on ADLs (activities of daily living), medications, diabetes control and management. The goal was that the resident will accept re-direction when making false accusations. Interventions included to identify stressful times of the day, schedule activities and tasks for other times, help the resident to cope using past successful coping mechanisms and praise/reward resident for demonstrating appropriate interactions with staff and others.

The undated active care plan also included that the resident had actual or suspected history of personal trauma, was abused by a babysitter at the age of 3 and had associated behaviors of mis-trust for other caregivers. The goal was that the resident will maintain psychosocial well-being. Interventions included to offer reassurance of safety and trust and restore a sense of control by honoring the resident's choices.

The nursing progress note dated July 26, 2024 included that the resident reported to the certified nursing assistant (CNA) that she had a bad day because something happened to her today that "brought back past memories." Per the documentation, the resident had "no unusual events reported other than officers here to visit for statement due to accusation regarding a staff member on another date and time." The documentation did not include whether the allegation was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement.

A late entry alert note dated August 1, 2024 included that the resident was seen by investigators before lunch; and that, the investigators went to speak to the Administrator.

There was no evidence found in the clinical record that this incident was reported to the administrator, State Agency (SA), Adult Protective Services (APS) and law enforcement until August 9, 2024.

Review of the SA complaint tracking system included a facility self-report dated August 9, 2024. The self-report revealed that during their investigation of another incident, the facility found in the clinical record that on July 24, 2024 resident #45 touched the leg of resident #12.

In an interview with resident #12 conducted on August 9, 2024 at 4:45 p.m., the resident stated that resident #45 would come up to her often up to twice daily and rub her knee and thigh; and that, the touch was very unwanted. The resident also stated that she had reported this to several nurses and certified nursing assistants (CNAs) who were often were present in the area when resident #45 touches her. The resident said that when this happens, the nurses and CNA who were present would laugh and think that it was funny, and would tell Resident #45 not to touch her. The resident stated that she can escape into her room which is her safe place because resident #45 does not enter her room. However, the resident stated that resident #45 would sit right outside her door and stare at her specifically when she changes clothing.

In an interview with a CNA (staff #6) conducted on August 9, 2024 at approximately 5:00 p.m., the CNA state that on Monday, August 5, 2024, she witnessed resident #45 rubbing the arm and back of resident #12 who had not in any way invited the touch. The CNA stated that she told resident #45 that he could not do that and then she went to report the incident to the RN (staff #5)

-Resident #23 admitted on March 31, 2023 with diagnoses of dementia and depression.

The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to p

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of two residents (#12 and #23) to be free from sexual abuse by another resident (#45). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. The census was 43.

Findings include:

-Resident #23 admitted on March 31, 2023 with diagnoses of dementia and depression.

The care plan dated May 16, 2023 revealed the resident had impaired cognitive function. The goal was that the quality of life will be nurtured and the resident will be exposed to pleasurable events each day. Intervention included to engage the resident's senses with pleasant smells.

The quarterly Minimum Data Set (MDS) assessment dated July 13, 2024 revealed that staff assessment that the resident had severe cognitive impairment.

A health status note dated August 7, 2024 included that the resident's Power of Attorney (POA) was informed of an inappropriate behavior displayed by a male resident to the resident #23; and that, the male resident was witnessed to touch the resident's arm/back.

An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that he was aware of the incident regarding resident #45 touching resident #23; and that, he was not part of the investigation. The SSD said that resident #23 was non-verbal and her eyes would track you when you are talking to her but cannot indicate a "yes" or "no" response.

-Resident #12 admitted on January 26, 2024 with diagnoses of hemiplegia and hemiparesis, major depressive disorder and anxiety.

The quarterly MDS assessment dated April 30, 2024 revealed a Brief Interview for Mental Status (BIMS) score 15 which indicated the resident had intact cognition.

The undated active care plan revealed that the resident was at risk for problematic behavior i.e. history of fabricating false accusations against staff that attempt to give directions on ADLs (activities of daily living), medications, diabetes control and management. The goal was that the resident will accept re-direction when making false accusations. Interventions included to identify stressful times of the day, schedule activities and tasks for other times, help the resident to cope using past successful coping mechanisms and praise/reward resident for demonstrating appropriate interactions with staff and others.

The undated active care plan also included that the resident had actual or suspected history of personal trauma, was abused by a babysitter at the age of 3 and had associated behaviors of mis-trust for other caregivers. The goal was that the resident will maintain psychosocial well-being. Interventions included to offer reassurance of safety and trust and restore a sense of control by honoring the resident's choices.

The nursing progress note dated July 26, 2024 included that the resident reported to the certified nursing assistant (CNA) that she had a bad day because something happened to her today that "brought back past memories." Per the documentation, the resident had "no unusual events reported other than officers here to visit for statement due to accusation regarding a staff member on another date and time."

There was also no evidence found in the clinical record that interventions were put in place to prevent the reoccurrence of resident #45 inappropriately touching or sexual advances to other female residents .

A late entry alert note dated August 1, 2024 included that the resident was seen by investigators before lunch; and that, the investigators went to speak to the Administrator.

In an interview with resident #12 conducted on August 9, 2024 at 4:45 p.m., the resident stated that resident #45 would come up to her often up to twice daily and rub her knee and thigh; and that, the touch was very unwanted. The resident also stated that she had reported this to several nurses and certified nursing assistants (CNAs) who were often were present in the area when resident #45 touches her. The resident said that when this happens, the nurses and CNA who were present would laugh and think that it was funny, and would tell Resident #45 not to touch her. The resident stated that she can escape into her room which is her safe place because resident #45 does not enter her room. However, the resident stated that resident #45 would sit right outside her door and stare at her specifically when she changes clothing.

An interview was conducted with the social service director (SSD) on August 9, 2024 at 1:30 p.m. The SSD that the administrator was the one investigating the incident on resident #45 patting another female resident on the shoulder.

In an interview with a CNA (staff #6) conducted on August 9, 2024 at approximately 5:00 p.m., the CNA state that on Monday, August 5, 2024, she witnessed resident #45 rubbing the arm and back of resident #12 who had not in any way invited the touch. The CNA stated that she told resident #45 that he could not do that and then she went to report the incident to the RN (staff #5)

-Resident #45 was admitted on February 15, 2023 with diagnosis of dementia.

The MDS assessment dated June 28, 2024 included a BIMS score of 7 indicating the resident had severe cognitive impairment.

The undated care plan revealed the resident had a behavior problem of inappropriate touching of a female resident related to dementia. The goal included that the resident will have no evidence of behavior problem of inappropriately touching. Interventions included 1:1 monitoring x 2 weeks, document his behavior every shift, report any sexual behavior to nurse and redirect as needed.

A progress note dated July 24, 2024 and written by a registered nurse (RN/staff #5) revealed that the resident touched a female resident on the leg; and that, it was unwanted. Per the documentation, the resident was redirected.

A health status note dated August 1, 2024 included that the resident was sexually explicit, was masturbating in his bed and was asking "where's that girl?" referring to the CNA.

A health status note written by a registered nurse (RN/staff #5) dated August 7, 2024 revealed that the resident was observed multiple times groping the breasts of a female resident. Per the documentation, staff explained to the resident the "wrongful behavior", was redirected and the resident showed "no signs of understanding."

Another health status note dated August 7, 2024 included that the resident was on alert charting related to inappropriate activities of wanting to touch other residents; and that, the resident was "monitored hourly regarding his whereabouts."

A behavior note dated August 7, 2024 included that the physician was notified regarding the resident's inappropriate behavior.

Despite the documentation that a resident was observed multiple times groping the breasts of a female resident, the facility self-report received on August 7, 2024 revealed that the resident was seen touching another resident; and that, the facility was "investigating specifically the location of resident touching."

A written statement from the RN (staff #5) dated August 7, 2024 included that the RN was at his medication cart on August 6, 2024 at approximately 5:30 p.m., he saw resident #45 was trying to touch resident #23; and that, the RN was able to intervene and redirect resident #45 before resident #45 could touch resident #23. Per the documentation, the RN assumed that resident #45 was going to grope the breasts of resident #23 because the RN had seen resident #45 was reaching towards the breasts of resident #23. Further, the documentation included that resident #45 attem

Based on record review and staff interview the facility failed to meet this requirement for separating the outpatient treatment center from the Long-term care facility. Failure to provide the minimum fire protection features could cause serious injury or death in the event of a fire

NFPA 101: Life Safety Code, 2012 Edition - Chapter 19 Existing Health Care Occupancies
19.1.2 Classification of Occupancy. 6.1.5.1 * Definition - Health Care Occupancy. An occupancy used to provide medical or other treatment or care simultaneously to four or more patients on an inpatient basis, where such patients are mostly incapable of self-preservation due to age, physical or mental disability, or because of security measures not under the occupants' control.
19.1.3.4 Contiguous Non-Health Care Occupancies. 19.1.3.4.1 * Ambulatory care facilities, medical clinics, and similar facilities that are contiguous to health care occupancies, but are primarily intended to provide outpatient services, shall be permitted to be classified as business occupancies or ambulatory health care facilities, provided that the facilities are separated from the health care occupancy by not less than 2-hour fire resistance-rated construction, and the facility is not intended to provide services simultaneously for four or more in patients who are litter borne. 19.1.3 Multiple Occupancies. 19.1.3.3 * Sections of health care facilities shall be permitted to be classified as other occupancies, provided that they meet all of the following conditions:
1. They are not intended to provide services simultaneously for four or more inpatients for purposes of housing, treatment, or customary access by inpatients incapable of self-preservation. 2. They are separated from areas of health care occupancies by construction having a minimum 2-hour fire resistance rating in accordance with Chapter 8. 3. For other than previously approved occupancy separation arrangements, the entire building is protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7. NFPA 101 2012 Edition, Section 8.2 Construction and Complementation.
8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters.
8.2.1.2 * NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification.
8.2.1.3 Where the building or facility includes additions or connected structures of different construction types, the rating and classification of the structure shall be based on one of the following:
(1) Separate buildings, if a 2-hour or greater vertically aligned fire barrier wall in accordance with NFPA 221, Standard for High Challenge Fire Walls, Fire Walls, and Fire Barrier Walls, exists between the portions of the building.
(2) Separate buildings, if provided with previously approved separations.
(3) Least fire-resistive construction type of the connected portions, if separation as specified in 8.2.1.3(1) or (2) is not provided.

Findings include:

Based on record review and staff interview on June 11, 2024, revealed the facility's outpatient rehabilitation is located in the middle of the building but the doors are not 90 minute rated. There are two doors leading into the rehabilitation center and office both are 20 min rated doors.

Management confirmed during the exit conference conducted on June 11, 2024, that the facility's outpatient rehabilitation does meet the requirements of NFPA 101 Chapter 19 Existing Health Care Occupancies for multiple occupancies separation.

Based on observation and staff interviews, the facility failed to ensure a remote stop or kill switch for the generator was installed. In addition, the remote monitoring panel was not operable at the time of the survey This affected the entire facility and could result in a loss of power due to a generator malfunction during an emergency power outage. Failure to have an emergency stop, or remote monitoring panel on the generator could cause destruction of the generator or harm to the residents and/or staff.

Code reference: NFPA 110 2010 Edition; Standard for Emergency and Standby Power Systems 5.6.5.6 All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation, located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building. 5.6.5.6 For systems located outdoors, the manual shut-down should be located external to the weatherproof enclosure and should be appropriately identified.

Findings include:

Based on observation and staff interviews on June 11, 2024, revealed the following:

1) the facility generator did not have the required remote stop/ kill switch.
2) the remote generator monitoring panel was not operable. The panel was located in the lobby but when inspected did not have any lights and failed to respond during repeated attempts using the test button. The generator was verified to be operable.

Management confirmed during the exit conference on June 11, 2024 that the facility failed to install a remote stop switch and ensure the remote monitoring panel was operable for the emergency diesel generator

Based on clinical record reviews, staff and resident interviews, and policies and procedures, the facility failed to ensure that advance directives were accurate for one resident (#9).

Findings include:

-Resident #9 was admitted to the facility on May 2, 2024, with a diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing.

Review of the clinical record revealed a prehospital medical care directive which included the resident was a Do Not Resuscitate (DNR) status. The medical care directive was signed by the resident on May 2, 2024.

However, review of the physician orders signed and dated May 8, 2024 revealed an order for a Full Code status.

An interview was conducted with resident #9 on May 30, 2024 at 01:00 PM who stated she had signed paperwork indicating her preferences for DNR. She stated "I have had a good life, I don't want any heroic measures done on me."

An interview was conducted with a Registered Nurse (staff #38) on May 30, 2024 at 1:16 p.m. She reviewed the resident's chart stating the residents current code status is a full code. She also reviewed the state forms noting the resident's actual status is a DNR. Registered Nurse (staff # 38) stated the orders needed to be corrected because they were not correct. Registered Nurse (staff #38) stated the risks associated with a resident's advance directives being incorrect and not reflecting the resident's decision could cause the resident to receive life saving measures when the directives were not to.

An interview was conducted with the Interim Director of Nursing (DON/staff #5) on May 30, 2024 at 1:31 p.m. She stated she has focused on the advance directives due to recent audits. When she reviewed the resident's clinical chart the code status had been changed to DNR. Registered Nurse (staff #38) informed the DON that the residents code status was Full Code and she had changed it to reflect the correct status of DNR. (DON/staff #5) stated that it is her expectations that advance directives be completed and be accurate.

Review of the facility policy titled Advance Directives (Revised September 2022) the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP).

Findings include:

An interview was conducted May 29, 2024 at 10:34 AM with Licensed Practical Nurse and designated Infection Preventionist (LPN/IP/Staff # 100) who stated although had coursework in Infection Prevention, did not have an infection prevention program certificate of completion at this time. Staff # 100 stated she had not taken the final cumulative assessment in order to receive her certificate of completion. Staff # 100 stated initially it was a collaborative task for whoever was present, but was handed-off the IP position by "fire" around March 15, 2024, after previous qualified Infection Preventionist/Director of Nursing left the facility.

An interview was conducted on May 29, 2024 at 01:07 PM with Interim Director of Nursing (IDON/Staff # 5) who confirmed that Staff # 100 was the designated Infection Preventionist at this time. Staff # 100 stated the facility is going to remove staff #100 out of her floor service duties, and whatever the requirement is, the facility will make sure staff #100 meet the requirement.

Review of "State Operations Manual, Appendix PP-2022 update" (revised June 2022), regulations revealed the facility must: designate one or more individuals as the Infection Preventionist (IP) who is responsible for the facility's Infection Prevention Control Program. The IP must \'a7483.80(b)(4) Have completed specialized training in infection prevention and control. The IP must be qualified by education, training, experience or certification. Training can occur through more than one course, but the IP must provide evidence of training through a certificate of completion or equivalent documentation.

Based on clinical record reviews, staff and resident interviews, and policies and procedures, the facility failed to ensure that advance directives were accurate for one resident (#9). The deficient practice could result in residents' wishes not being honored.

Findings include:

-Resident #9 was admitted to the facility on May 2, 2024, with a diagnosis of displaced intertrochanteric fracture of right femur, subsequent encounter for closed fracture with routine healing, age-related osteoporosis with current pathological fracture, right femur, subsequent encounter for fracture with routine healing.

Review of the clinical record revealed a prehospital medical care directive which included the resident was a Do Not Resuscitate (DNR) status. The medical care directive was signed by the resident on May 2, 2024.

However, review of the physician orders signed and dated May 8, 2024 revealed an order for a Full Code status.

An interview was conducted with resident #9 on May 30, 2024 at 01:00 PM who stated she had signed paperwork indicating her preferences for DNR. She stated "I have had a good life, I don't want any heroic measures done on me."

An interview was conducted with a Registered Nurse (staff #38) on May 30, 2024 at 1:16 p.m. She reviewed the resident's chart stating the residents current code status is a full code. She also reviewed the state forms noting the resident's actual status is a DNR. Registered Nurse (staff # 38) stated the orders needed to be corrected because they were not correct. Registered Nurse (staff #38) stated the risks associated with a resident's advance directives being incorrect and not reflecting the resident's decision could cause the resident to receive life saving measures when the directives were not to.

An interview was conducted with the Interim Director of Nursing (DON/staff #5) on May 30, 2024 at 1:31 p.m. She stated she has focused on the advance directives due to recent audits. When she reviewed the resident's clinical chart the code status had been changed to DNR. Registered Nurse (staff #38) informed the DON that the residents code status was Full Code and she had changed it to reflect the correct status of DNR. (DON/staff #5) stated that it is her expectations that advance directives be completed and be accurate.

Review of the facility policy titled Advance Directives (Revised September 2022) the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. Advance directives are honored in accordance with state law and facility policy.

Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#150 and #56) included documentation of orientation and in-service education as required by policies and procedure.

Findings include:

The personnel file of a registered nurse (RN/staff 150) revealed a hire date of April 26, 2021. The file revealed no evidence of infection control and Abuse/neglect/exploitation training since January and July, 2022.

The personnel file of a activity coordinator (staff 56) revealed a hire date of January 21, 2014. The file revealed no evidence of Abuse/neglect/exploitation training since May, 2016, no evidence of Resident rights training since June, 2017 and no evidence of Infection control and prevention training since December, 2018.

An Interview was conducted on May 29, 2024 at 2:12 p.m. with the Human Resource Director (staff # 125), she stated that she is not sure about orientation and in-service education policy. She further stated that Relias send a reminder when staff training class is due, it's also self-monitoring thing and she also sent reminder to staff and supervisor if they are way behind.

An Interview was conducted on May 30, 2024 at 9:15 a.m. with the Interim Director of Nursing (staff # 5), she stated that there are certain in-service training done through relias. She further stated that she has been here for 2 months so she is not sure about in-service training but if she is here then she will do competency and also access staff before the year. She also stated risk for staff not getting training that they won't be updated to process and procedure and it would cause problem to residents.

Review of facility policy regarding "Elder Abuse Prevention Identification, response, and reporting", revised on 10/20/2023 stated that onboarding and annual education is necessary for all team members to understand their role in abuse prevention, management, and reporting.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure care plan was revised for one resident (#53).

Findings include:

Resident # 53 was admitted to the facility on July 3, 2024 and discharged July 19, 2023, with diagnoses that included Nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing, Pain in left ankle and joints of left foot, Unspecified open wound, right foot, subsequent encounter, Unspecified open wound, left foot, subsequent encounter, Unspecified open wound, right lower leg, subsequent encounter, Unspecified open wound, left lower leg, subsequent encounter, Unspecified osteoarthritis, unspecified site, Nondisplaced fracture of medial malleolus of right tibia, initial encounter for closed fracture.

An annual Minimum Data Set assessment dated July 9, 2023 revealed a Brief Interview for Mental Status (BIMS) was conducted revealing a BIMS score of 15 indicating resident cognition is intact. Review of Section G revealed resident required extensive assist with toileting, transfers, dressing, personal hygiene and required two plus persons for physical assist with transfer, balance during transitions and walking. Functional limitation in range of motion revealed impairment on one side with lower extremity, used wheelchair and walker for mobility.

Review of the comprehensive care plan effective dated 7/12/2023 and created on 7/12/2023 revealed the resident was at risk for falls related to weakness, impaired mobility, foot wounds, medications.

Review of Progress note dated 7/18/2023 at 12:56 pm stated that the resident reported she had fall in restroom on 7/16/2023. The note further stated that on 7/16/2024, she was assisted by a Certified Nursing Assistant (CNA) in the restroom and her legs became weak and she was lowered to the floor with assistance from the CNA. The note stated the resident did not hit her feet or leg but stated her ankle might have turned when she was sitting down.

Further review of the care plan revealed that it had not been revised to reflect the level of assistance required for resident #53 with toileting, transfers, dressing, personal hygiene.

A phone interview was conducted with a Certified Nursing Assistant (CNA/staff #105) on May 30. 2024 at 12:19 p.m. She stated she had previously worked for the facility 2022-2023 and could recall the incident involving resident #53. She stated she had assisted the resident with toileting when the resident wanted to sit down due to anxiety and feeling weak. CNA/staff #105 stated using the gait belt, she sat the resident on the floor, because she couldn't place her back on the toilet due to feces on the toilet seat. CNA/staff #105 stated she had requested assistance from Registered Nurse (RN/Staff #39) prior to assisting the resident to the bathroom. She stated she waited 10-15 minutes for assistance, but (RN/Staff #39) never came to assist her. She stated the reason she asked for help was due to the resident complaining of feeling weak the day prior. She stated she was asked by the former DON to change her statement regarding asking for assistance from the nurse prior and that the she was aware the resident was a two-person assist with toileting. (CNA/staff #105) stated she refused to change her statement because she had looked at the resident's care plan and there nothing care planned indicating a non-weight bearing status or the need for a two-person transfer.

An interview was conducted with a Registered Nurse (RN/staff #39) on May 30, 2024 at approximately 2:00 p.m. She stated she could not recall any of the incident, but believed the resident was a two- person transfer and that (CNA/staff #105) did not request her assistance with transfer of the resident. She stated the resident had an x-ray completed at the facility and was transferred to the hospital.

An interview was conducted with the Interim Director of Nursing (DON/staff #5) on May 31, 2024 at 8:36 a.m. She stated that when a CNA needs information regarding a resident's level of assistance they would find this information in the resident's care plan and that they do not have access to the MDS. She further stated her expectations are that a resident's level for assistance would be in the care plan, shared in report and in the nurses charting. (DON/staff #5) reviewed the MDS for resident #53 confirming the resident is a three indicating the resident is an extensive assist with two plus people. (DON/staff #5) also reviewed the current plan stating the care plan did not reflect the level of assistance required for resident transfers and that the care plan should reflect the MDS.

A facility policy regarding Care Plans Baseline included the following: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions (EBP), signage and personal protective equipment were in-place to help prevent development or transmission of infections. The deficient practice could result in development or transmission of infections within the facility.

Findings Include:

Resident #352 was admitted on September 10, 2022 with diagnosis including sepsis, unspecified organism, onset date May 22 2024, Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere onset May 22, 2024, Urinary tract infection, site not specified New UTI 3.19.24, Pressure ulcer of left heel, unstageable May 22, 2024, Benign prostatic hyperplasia with lower urinary tract symptom.

A review of the physician orders revealed an order dated February 7, 2024 for an indwelling catheter size 16 French with a 15cc bulb.

A review of the quarterly MDS (minimum data set) dated May 17, 2024 revealed that the resident BIMS (brief interview of mental status) was unable to be completed. The MDS further revealed that resident #352 had an in-dwelling catheter in place and a diagnosis of obstructive uropathy.

A review of the care plan revealed that an indwelling catheter was in place for an obstructive uropathy. The care plan further notes interventions of monitoring for pain or discomfort, monitoring for UTI's (urinary tract infections), catheter care per shift and reporting any unusual observations to the nurse.

An observation was conducted on May 28, 2024 at 10:46 AM. It was observed that there was no signage outside of the room of resident #352 alerting to enhanced barrier precautions, nor was PPE (personal protective equipment) visible outside of the resident's room. A box of gloves were observed in the resident's room, but no other PPE was present either within or directly outside of the resident's room.

A secondary observation was conducted on May 28, 2024 at 2:37 PM. No signage for enhanced barrier precautions or PPE outside of the resident # 352's room were observed.

An interview was conducted on May 29, 2024 at 11:25 PM with staff #100 Infection Preventionist /Licensed Practical Nurse (LPN/IP). Staff #100 Stated that she was recently placed as the IP person after assisting the facility during a Covid outbreak and "was thrown in by fire" as the Infection Preventionist. Staff #100 EBP was placed for all residents with catheters and wounds the morning of May 20, 2024. Staff #100 stated she was aware of the recent changes with CMS guidelines regarding EBP, but does not know why the EBP precautions were not previously placed.

An interview was conducted on May 30, 2024 at 1:49 PM with staff #80 CNA (Certified Nursing Assistant). Staff #8 stated that resident # 352 has an indwelling catheter and has had one for a while. She stated that she had been informed on May 30, 2024 that she was to use precautions when caring for resident #352 catheter, using gown and gloves. She stated there were no Enhanced Barrier Precaution prior to May 30, 2024 for resident #352. Staff #8 stated she could not recall receiving training on transmission based or enhanced barrier precautions, she may have had training through Relias, but did not know the difference between the two precautions.

An interview was conducted on May 29, 2024 at 01:07 PM with staff #5 Interim DON (Director of Nursing). Staff #5 stated that not having anyone available in the role as IP and her short-term role as the DON has been part of the conversation and in hindsight it was not something they have been practicing.

Based on staff interviews and facility policy, the facility failed to designate a qualified individual as the Infection Preventionist (IP). The deficient practice could result in improper infection prevention practices in the facility.

Findings include:

An interview was conducted May 29, 2024 at 10:34 AM with Licensed Practical Nurse and designated Infection Preventionist (LPN/IP/Staff # 100) who stated although had coursework in Infection Prevention, did not have an infection prevention program certificate of completion at this time. Staff # 100 stated she had not taken the final cumulative assessment in order to receive her certificate of completion. Staff # 100 stated initially it was a collaborative task for whoever was present, but was handed-off the IP position by "fire" around March 15, 2024, after previous qualified Infection Preventionist/Director of Nursing left the facility.

An interview was conducted on May 29, 2024 at 01:07 PM with Interim Director of Nursing (IDON/Staff # 5) who confirmed that Staff # 100 was the designated Infection Preventionist at this time. Staff # 100 stated the facility is going to remove staff #100 out of her floor service duties, and whatever the requirement is, the facility will make sure staff #100 meet the requirement.

Review of "State Operations Manual, Appendix PP-2022 update" (revised June 2022), regulations revealed the facility must: designate one or more individuals as the Infection Preventionist (IP) who is responsible for the facility's Infection Prevention Control Program. The IP must \'a7483.80(b)(4) Have completed specialized training in infection prevention and control. The IP must be qualified by education, training, experience or certification. Training can occur through more than one course, but the IP must provide evidence of training through a certificate of completion or equivalent documentation.

Based on review of employee personnel file, staff interviews and policy review, the facility failed to ensure personnel records for 2 staff (#150 and #56) included documentation of orientation and in-service education as required by policies and procedure. The deficient practice could result in inadequate care of residents.

Findings include:

Review of the personnel file of a registered nurse (RN/staff 150) revealed a hire date of April 26, 2021. The file revealed no evidence of infection control and Abuse/neglect/exploitation training since January and July, 2022.

Review of the personnel file of a activity coordinator (staff 56) revealed a hire date of January 21, 2014. The file revealed no evidence of Abuse/neglect/exploitation training since May, 2016, no evidence of Resident rights training since June, 2017 and no evidence of Infection control and prevention training since December, 2018.

An Interview was conducted on May 29, 2024 at 2:12 p.m. with the Human Resource Director (staff # 125), she stated that she is not sure about orientation and in-service education policy. She further stated that Relias send a reminder when staff training class is due, it's also self-monitoring thing and she also sent reminder to staff and supervisor if they are way behind.

An Interview was conducted on May 30, 2024 at 9:15 a.m. with the Interim Director of Nursing (staff # 5), she stated that there are certain in-service training done through relias. She further stated that she has been here for 2 months so she was not sure about in-service training but she will do competency and also access staff before the year. She also stated risk for staff not getting training that they won't be updated to process and procedure and it would cause problem to residents.

Review of facility policy regarding "Elder Abuse Prevention Identification, response, and reporting", revised on 10/20/2023 stated that onboarding and annual education is necessary for all team members to understand their role in abuse prevention, management, and reporting.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure care plan was revised for one resident (#53).

Findings include:

Resident # 53 was admitted to the facility on July 3, 2024 and discharged July 19, 2023, with diagnoses that included Nondisplaced fracture of medial malleolus of left tibia, subsequent encounter for closed fracture with routine healing, Pain in left ankle and joints of left foot, Unspecified open wound, right foot, subsequent encounter, Unspecified open wound, left foot, subsequent encounter, Unspecified open wound, right lower leg, subsequent encounter, Unspecified open wound, left lower leg, subsequent encounter, Unspecified osteoarthritis, unspecified site, Nondisplaced fracture of medial malleolus of right tibia, initial encounter for closed fracture.

An annual Minimum Data Set assessment dated July 9, 2023 revealed a Brief Interview for Mental Status (BIMS) was conducted revealing a BIMS score of 15 indicating resident cognition is intact. Review of Section G revealed resident required extensive assist with toileting, transfers, dressing, personal hygiene and required two plus persons for physical assist with transfer, balance during transitions and walking. Functional limitation in range of motion revealed impairment on one side with lower extremity, used wheelchair and walker for mobility.

Review of the comprehensive care plan effective dated 7/12/2023 and created on 7/12/2023 revealed the resident was at risk for falls related to weakness, impaired mobility, foot wounds, medications.

Review of Progress note dated 7/18/2023 at 12:56 pm stated that the resident reported she had fall in restroom on 7/16/2023. The note further stated that on 7/16/2024, she was assisted by a Certified Nursing Assistant (CNA) in the restroom and her legs became weak and she was lowered to the floor with assistance from the CNA. The note stated the resident did not hit her feet or leg but stated her ankle might have turned when she was sitting down.

Further review of the care plan revealed that it had not been revised to reflect the level of assistance required for resident #53 with toileting, transfers, dressing, personal hygiene.

A phone interview was conducted with a Certified Nursing Assistant (CNA/staff #105) on May 30. 2024 at 12:19 p.m. She stated she had previously worked for the facility 2022-2023 and could recall the incident involving resident #53. She stated she had assisted the resident with toileting when the resident wanted to sit down due to anxiety and feeling weak. CNA/staff #105 stated using the gait belt, she sat the resident on the floor, because she couldn't place her back on the toilet due to feces on the toilet seat. CNA/staff #105 stated she had requested assistance from Registered Nurse (RN/Staff #39) prior to assisting the resident to the bathroom. She stated she waited 10-15 minutes for assistance, but (RN/Staff #39) never came to assist her. She stated the reason she asked for help was due to the resident complaining of feeling weak the day prior. She stated she was asked by the former DON to change her statement regarding asking for assistance from the nurse prior and that the she was aware the resident was a two-person assist with toileting. (CNA/staff #105) stated she refused to change her statement because she had looked at the resident's care plan and there nothing care planned indicating a non-weight bearing status or the need for a two-person transfer.

An interview was conducted with a Registered Nurse (RN/staff #39) on May 30, 2024 at approximately 2:00 p.m. She stated she could not recall any of the incident, but believed the resident was a two- person transfer and that (CNA/staff #105) did not request her assistance with transfer of the resident. She stated the resident had an x-ray completed at the facility and was transferred to the hospital.

An interview was conducted with the Interim Director of Nursing (DON/staff #5) on May 31, 2024 at 8:36 a.m. She stated that when a CNA needs information regarding a resident's level of assistance they would find this information in the resident's care plan and that they do not have access to the MDS. She further stated her expectations are that a resident's level for assistance would be in the care plan, shared in report and in the nurses charting. (DON/staff #5) reviewed the MDS for resident #53 confirming the resident is a three indicating the resident is an extensive assist with two plus people. (DON/staff #5) also reviewed the current plan stating the care plan did not reflect the level of assistance required for resident transfers and that the care plan should reflect the MDS.

A facility policy regarding Care Plans Baseline included the following: A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission

Based on review of clinical records and policy, observations, and staff interviews the facility failed to ensure transmission-based precautions, particularly enhanced barrier precautions (EBP), signage and personal protective equipment were in-place to help prevent development or transmission of infections.

Findings Include:

Resident #352 was admitted on September 10, 2022 with diagnosis including sepsis, unspecified organism, onset date May 22 2024, Unspecified Escherichia coli [E. coli] as the cause of diseases classified elsewhere onset May 22, 2024, Urinary tract infection, site not specified New UTI 3.19.24, Pressure ulcer of left heel, unstageable May 22, 2024, Benign prostatic hyperplasia with lower urinary tract symptom.

A review of the physician orders revealed an order dated February 7, 2024 for an indwelling catheter size 16 French with a 15cc bulb.

A review of the quarterly MDS (minimum data set) dated May 17, 2024 revealed that the resident BIMS (brief interview of mental status) was unable to be completed. The MDS further revealed that resident #352 had an in-dwelling catheter in place and a diagnosis of obstructive uropathy.

A review of the care plan revealed that an indwelling catheter was in place for an obstructive uropathy. The care plan further notes interventions of monitoring for pain or discomfort, monitoring for UTI's (urinary tract infections), catheter care per shift and reporting any unusual observations to the nurse.

An observation was conducted on May 28, 2024 at 10:46 AM. It was observed that there was no signage outside of the room of resident #352 alerting to enhanced barrier precautions, nor was PPE (personal protective equipment) visible outside of the resident's room. A box of gloves were observed in the resident's room, but no other PPE was present either within or directly outside of the resident's room.

A secondary observation was conducted on May 28, 2024 at 2:37 PM. No signage for enhanced barrier precautions or PPE outside of the resident # 352's room were observed.

An interview was conducted on May 29, 2024 at 11:25 PM with staff #100 Infection Preventionist /Licensed Practical Nurse (LPN/IP). Staff #100 Stated that she was recently placed as the IP person after assisting the facility during a Covid outbreak and "was thrown in by fire" as the Infection Preventionist. Staff #100 EBP was placed for all residents with catheters and wounds the morning of May 20, 2024. Staff #100 stated she was aware of the recent changes with CMS guidelines regarding EBP, but does not know why the EBP precautions were not previously placed.

An interview was conducted on May 30, 2024 at 1:49 PM with staff #80 CNA (Certified Nursing Assistant). Staff #8 stated that resident # 352 has an indwelling catheter and has had one for a while. She stated that she had been informed on May 30, 2024 that she was to use precautions when caring for resident #352 catheter, using gown and gloves. She stated there were no Enhanced Barrier Precaution prior to May 30, 2024 for resident #352. Staff #8 stated she could not recall receiving training on transmission based or enhanced barrier precautions, she may have had training through Relias, but did not know the difference between the two precautions.

An interview was conducted on May 29, 2024 at 01:07 PM with staff #5 Interim DON (Director of Nursing). Staff #5 stated that not having anyone available in the role as IP and her short-term role as the DON has been part of the conversation and in hindsight it was not something they have been practicing.

Based on staff interviews, review of the clinical record, facility documentation, and policy and procedure, the facility failed to notify one resident's (#1) representative timely when there was a significant change in the resident's condition related to pressure ulcers. The deficient practice could result in resident representatives not being notified when residents experience a change in condition.

Findings include:

Resident # 1 was admitted on February 25, 2023 with diagnoses of anxiety, femur fracture, need for assistance with personal care, fall, femur fracture, dementia, hemiplegia affecting left non-dominant side, and unspecified hearing loss bilateral.

The admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated resident had intact cognition. The assessment also revealed no evidence of pressure ulcers at admission.

The admission progress note dated February 25, 2023 revealed no evidence of break in skin integrity to bilateral heel ulcers. The assessment included bruising to the right arm and discoloration to bilateral lower extremities, and surgical incision to right hip.

Review of wound assessments dated March 8, 2023 revealed deep tissue ulcers to the right and left heel ulcers.

The nursing progress notes dated March 12, 2023 revealed purplish red discoloration to bilateral heels; and that, an order for betadine was received.

A physician orders dated February through March 2023 revealed no orders for care/treatment of the right and left heel ulcers from March 12 through 21, 2023.

The physician order dated May 22, 2023 revealed a treatment order to apply Santyl to the right and left heel pressure injury; and, to monitor for signs/symptoms of infection.

Despite identification of pressure ulcers to the right and left heels, the clinical record revealed no evidence that the resident's representative was notified of the pressure ulcers from March 12 through 25, 2023.

The nursing progress notes dated March 26, 2023 revealed the resident's representative was notified of the presence of the bilateral heel ulcers at the time of discharge.

The discharge summary dated March 25, 2023 revealed evidence of right and left heel pressure ulcers present upon discharge.

An interview was conducted on June 6, 2023 at 2:55 p.m. with a registered nurse (RN/staff #20), who stated that when a pressure ulcer is identified the expectation was to notify the provider and family. She further stated that notification should be documented in the progress notes; and that, notification to the family should be done on the shift that it occurred or the wound was identified and prior to the end of the shift. She stated that the sooner the family was notified, the better. Regarding resident #1, the RN stated that the expectation was that the resident had been notified of the heel ulcers; and that, the notification should have been documented in the clinical record.

An interview with the Director of Nursing (DON/staff #21) was conducted on June 6, 2023 at 1:24 p.m. The DON stated that a facility acquired pressure ulcer would be considered a change of condition; and when this occurs, the provider and family should be notified. She also stated that the notification should occur during the shift that it was identified, and be documented in the progress notes. A review of the clinical record was conducted with the DON who stated that there was no evidence that the resident's representative had been notified regarding the change of condition of pressure ulcers for resident #1; and that, this did not meet her expectations.

Review of the facility policy on Change in a Resident's Condition or Status, revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical condition or status. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff. A nurse will notify the resident's representative when the resident is involved in any accident/incident that results in injury and when there is a significant change in the resident's physical status.

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that a care plan was implemented for one resident (#1) regarding pressure ulcer/skin impairment interventions. The deficient practice could result in a plan of care that did not meet the resident's needs.

Findings include:

Resident # 1 was admitted on February 25, 2023 with diagnoses of anxiety, femur fracture, need for assistance with personal care, fall, femur fracture, dementia, hemiplegia affecting left non-dominant side, and unspecified hearing loss bilateral.

A nursing admission evaluation dated February 25, 2023 revealed no evidence that the resident had deep tissue injury of bilateral heels.

The care plan dated February 25, 2023 revealed the resident had pressure ulcers and skin integrity as focus of care. Intervention included to use pillows, pads, or wedges to reduce pressure on heels and pressure points, turn/reposition, and, if skin impairment occurs monitor/document location, size and treatment of skin injury and report any signs of skin breakdown, abnormalities, failure to heal, signs/symptoms of infection, maceration to provider.

Review of the February 2023 Treatment Administration Report (TAR) revealed no evidence of use pressure relief to the bilateral heels.

There was no evidence found in the clinical record that pressure relief to bilateral heels was implemented as care planned.

The care plan dated March 3, 2023 revealed the resident had an unstageable pressure injury, deep tissue injury (DTI). Interventions included to float heels while in bed or chair, wear heel protectors, secure assistance for turning, positioning and transfer, reposition every one to two hours or more often and use low air loss mattress to bed and pads when sitting. The care plan included that the resident would not keep heel protectors on.

The wound assessments for right and left heel ulcers dated March 8, 2023 revealed deep tissue ulcers to the right and left heel ulcers; and that, foam heel protector was applied.

The physician order dated March 8, 2023 revealed an order for sureprep to bilateral heel pressure injury every shift, apply foam heel protectors at all times, offload both heels when in bed.

There was no evidence found in the clinical record that turning/repositioning, or heel elevation was implemented as care planned after March 8, 2023.

The nursing progress notes dated March 12, 2023 revealed purplish red discoloration to bilateral heels; and that, an order for betadine was received.

The TAR for March 2023 revealed no evidence of that pressure relief was provided or implemented as care planned from March 1 through March 12, 2023

Succeeding wound assessments dated March 17 and 22, 2023 revealed no evidence that the foam heel protector was applied to bilateral heels.

Continued review of the clinical record revealed that wound measurements increased between March 8, 2023 through March 22, 2023.

The physician order dated May 22, 2023 revealed a treatment order to apply Santyl to the right and left heel pressure injury; and, to monitor for signs/symptoms of infection.

An interview was conducted on June 6, 2023 at 2:58 p.m. with a certified nursing assistant (CNA/staff #22) who stated that residents were repositioned every 30 minutes; and that, pillows are used to offload the heels. However, the CNA stated that this was not documented in the clinical record.

An interview with a registered nurse (RN/staff #20) was conducted on June 6, 2023 at 2:25 p.m. The RN stated that the facility uses pillows or foam boots for pressure relief to resident's heels; and that, there should be an order for the pressure relieving devices and for turning and repositioning. She stated that pressure relief to the heels should be documented in the progress notes, and in the TAR. Regarding resident #1, the RN stated that the resident developed deep tissue injuries on bilateral heels; and that they were offloading her heels and the resident was on a low air loss mattress.

In an interview with the Director of Nursing (DON/staff #21) conducted on June 6, 2023 at 1:24 p.m., the DON stated that if there was not a physician order for heel protectors, nursing should document off-loading/pressure relief in the daily nursing notes. She also said that any orders for pressure relief would be documented on the TAR. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence of orders for pressure relief to the bilateral heels of resident #1; and, there was no evidence found that the resident was turned/repositioned, and had heels offloaded. She stated that these interventions should be documented in the progress notes, or in the TAR. Further, the DON stated that there was no evidence that the bilateral heel ulcers were offloaded per the care plan from March 17, 2023 through March 26, 2023. The DON stated that the expectation was to follow the interventions as care planned. She stated that she could not say if pressure relief occurred because there was no documentation found in the clinical record. The DON stated that the risk of not following the interventions as care planned for pressure relief could result in the wound getting larger, or the pressure not being relieved.

Review of the facility policy on Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed the nurse shall describe and document/report current treatments including support surfaces. The physician will order pertinent wound treatments, including pressure reduction surfaces, dressings and application of topical agents. The physician will guide the care plan as appropriate, especially when wounds are not healing, or new wounds develop despite existing interventions. Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions.

The facility policy on Care Planning, revealed resident care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The IDT team is responsible for the development of resident care plans.

Based on staff interviews, review of the clinical record, facility documentation, and policy and procedure, the facility failed to notify one resident's (#1) representative timely when there was a significant change in the resident's condition related to pressure ulcers.

Findings include:

Resident # 1 was admitted on February 25, 2023 with diagnoses of anxiety, femur fracture, need for assistance with personal care, fall, femur fracture, dementia, hemiplegia affecting left non-dominant side, and unspecified hearing loss bilateral.

The admission Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 14 which indicated resident had intact cognition. The assessment also revealed no evidence of pressure ulcers at admission.

The admission progress note dated February 25, 2023 revealed no evidence of break in skin integrity to bilateral heel ulcers. The assessment included bruising to the right arm and discoloration to bilateral lower extremities, and surgical incision to right hip.

Review of wound assessments dated March 8, 2023 revealed deep tissue ulcers to the right and left heel ulcers.

The nursing progress notes dated March 12, 2023 revealed purplish red discoloration to bilateral heels; and that, an order for betadine was received.

A physician orders dated February through March 2023 revealed no orders for care/treatment of the right and left heel ulcers from March 12 through 21, 2023.

The physician order dated May 22, 2023 revealed a treatment order to apply Santyl to the right and left heel pressure injury; and, to monitor for signs/symptoms of infection.

Despite identification of pressure ulcers to the right and left heels, the clinical record revealed no evidence that the resident's representative was notified of the pressure ulcers from March 12 through 25, 2023.

The nursing progress notes dated March 26, 2023 revealed the resident's representative was notified of the presence of the bilateral heel ulcers at the time of discharge.

The discharge summary dated March 25, 2023 revealed evidence of right and left heel pressure ulcers present upon discharge.

An interview was conducted on June 6, 2023 at 2:55 p.m. with a registered nurse (RN/staff #20), who stated that when a pressure ulcer is identified the expectation was to notify the provider and family. She further stated that notification should be documented in the progress notes; and that, notification to the family should be done on the shift that it occurred or the wound was identified and prior to the end of the shift. She stated that the sooner the family was notified, the better. Regarding resident #1, the RN stated that the expectation was that the resident had been notified of the heel ulcers; and that, the notification should have been documented in the clinical record.

An interview with the Director of Nursing (DON/staff #21) was conducted on June 6, 2023 at 1:24 p.m. The DON stated that a facility acquired pressure ulcer would be considered a change of condition; and when this occurs, the provider and family should be notified. She also stated that the notification should occur during the shift that it was identified, and be documented in the progress notes. A review of the clinical record was conducted with the DON who stated that there was no evidence that the resident's representative had been notified regarding the change of condition of pressure ulcers for resident #1; and that, this did not meet her expectations.

Review of the facility policy on Change in a Resident's Condition or Status, revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical condition or status. A significant change of condition is a major decline or improvement in the resident's status that will not normally resolve itself without intervention by staff. A nurse will notify the resident's representative when the resident is involved in any accident/incident that results in injury and when there is a significant change in the resident's physical status.

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure that a care plan was implemented for one resident (#1) regarding pressure ulcer/skin impairment interventions.

Findings include:

Resident # 1 was admitted on February 25, 2023 with diagnoses of anxiety, femur fracture, need for assistance with personal care, fall, femur fracture, dementia, hemiplegia affecting left non-dominant side, and unspecified hearing loss bilateral.

A nursing admission evaluation dated February 25, 2023 revealed no evidence that the resident had deep tissue injury of bilateral heels.

The care plan dated February 25, 2023 revealed the resident had pressure ulcers and skin integrity as focus of care. Intervention included to use pillows, pads, or wedges to reduce pressure on heels and pressure points, turn/reposition, and, if skin impairment occurs monitor/document location, size and treatment of skin injury and report any signs of skin breakdown, abnormalities, failure to heal, signs/symptoms of infection, maceration to provider.

Review of the February 2023 Treatment Administration Report (TAR) revealed no evidence of use pressure relief to the bilateral heels.

There was no evidence found in the clinical record that pressure relief to bilateral heels was implemented as care planned.

The care plan dated March 3, 2023 revealed the resident had an unstageable pressure injury, deep tissue injury (DTI). Interventions included to float heels while in bed or chair, wear heel protectors, secure assistance for turning, positioning and transfer, reposition every one to two hours or more often and use low air loss mattress to bed and pads when sitting. The care plan included that the resident would not keep heel protectors on.

The wound assessments for right and left heel ulcers dated March 8, 2023 revealed deep tissue ulcers to the right and left heel ulcers; and that, foam heel protector was applied.

The physician order dated March 8, 2023 revealed an order for sureprep to bilateral heel pressure injury every shift, apply foam heel protectors at all times, offload both heels when in bed.

There was no evidence found in the clinical record that turning/repositioning, or heel elevation was implemented as care planned after March 8, 2023.

The nursing progress notes dated March 12, 2023 revealed purplish red discoloration to bilateral heels; and that, an order for betadine was received.

The TAR for March 2023 revealed no evidence of that pressure relief was provided or implemented as care planned from March 1 through March 12, 2023

Succeeding wound assessments dated March 17 and 22, 2023 revealed no evidence that the foam heel protector was applied to bilateral heels.

Continued review of the clinical record revealed that wound measurements increased between March 8, 2023 through March 22, 2023.

The physician order dated May 22, 2023 revealed a treatment order to apply Santyl to the right and left heel pressure injury; and, to monitor for signs/symptoms of infection.

An interview was conducted on June 6, 2023 at 2:58 p.m. with a certified nursing assistant (CNA/staff #22) who stated that residents were repositioned every 30 minutes; and that, pillows are used to offload the heels. However, the CNA stated that this was not documented in the clinical record.

An interview with a registered nurse (RN/staff #20) was conducted on June 6, 2023 at 2:25 p.m. The RN stated that the facility uses pillows or foam boots for pressure relief to resident's heels; and that, there should be an order for the pressure relieving devices and for turning and repositioning. She stated that pressure relief to the heels should be documented in the progress notes, and in the TAR. Regarding resident #1, the RN stated that the resident developed deep tissue injuries on bilateral heels; and that they were offloading her heels and the resident was on a low air loss mattress.

In an interview with the Director of Nursing (DON/staff #21) conducted on June 6, 2023 at 1:24 p.m., the DON stated that if there was not a physician order for heel protectors, nursing should document off-loading/pressure relief in the daily nursing notes. She also said that any orders for pressure relief would be documented on the TAR. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence of orders for pressure relief to the bilateral heels of resident #1; and, there was no evidence found that the resident was turned/repositioned, and had heels offloaded. She stated that these interventions should be documented in the progress notes, or in the TAR. Further, the DON stated that there was no evidence that the bilateral heel ulcers were offloaded per the care plan from March 17, 2023 through March 26, 2023. The DON stated that the expectation was to follow the interventions as care planned. She stated that she could not say if pressure relief occurred because there was no documentation found in the clinical record. The DON stated that the risk of not following the interventions as care planned for pressure relief could result in the wound getting larger, or the pressure not being relieved.

Review of the facility policy on Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed the nurse shall describe and document/report current treatments including support surfaces. The physician will order pertinent wound treatments, including pressure reduction surfaces, dressings and application of topical agents. The physician will guide the care plan as appropriate, especially when wounds are not healing, or new wounds develop despite existing interventions. Current approaches should be reviewed for whether they remain pertinent to the resident's medical conditions.

The facility policy on Care Planning, revealed resident care plans are based on resident assessments and developed by an interdisciplinary team (IDT). The IDT team is responsible for the development of resident care plans.

Based on observation the facility failed to have a complete 15 second sign posted at an exterior exit door. Failure to have the proper signage posted could cause a delay in an emergency and could cause harm to the patients in event of a fire.

Findings include:

NFPA 101 Life Safety Code, 2012 Chapter 19, Section 19.2 Means of Egress Requirements. Section 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and exit access shall be in accordance with Chapter 7, unless modified by 19.2.2 through 19.2.11. Section 7.2.1.6* Special Locking Arrangements. Section 7.2.1.6.1 Delayed Egress Locking Arrangements. Section 7.2.1.6.1.1 Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. Section 7.2.1.6.1.1 # (4) A readily visible durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located o the door leaf adjacent to the release device in the direction of egress: "PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS".

Observations made while on tour on February 2, 2023, revealed the exit door for the south east wing had damaged/missing letters for the delay egress door. The door stated "5 seconds".

During the exit conference on February 2, 2023, the above findings were again acknowledged by management team.

Based on observation the facility failed to maintain doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer which will cause harm to the patients and/or staff.

NFPA 101, Life Safety Code, 2012 edition, Chapter 19, Section 19.3.6.3.5. "Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction."

Findings include:

Observations made while on tour on February 2, 2023, revealed resident room door 8143 was delaminating on thr upper hinge side.

During the exit conference conducted on February 2, 2023, the above findings were again acknowledged by the management team.

Based on observation the facility failed to segregate empty and full oxygen E- type cylinders in a separate storage rack or stand. Failing to segregate compressed gas medical cylinders could cause harm to the patients if a full bottle is needed in an emergency for the patients.

NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.2.4 "Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities." NFPA 99 2012 Edition Chapter 11 Section 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders.

Findings include:

Observations made while on tour on February 2, 2023, revealed in the north oxygen storage room an empty E-type Cylinder was located on the full storage side.

During the exit conference conducted on February 2, 2023, the above findings were again acknowledged by the management team.

Based on review of records, staff interviews and review of policies and procedures, the facility failed to ensure that two residents (#24, #14) were provided care and services that met professional standards of quality resulting in the residents receiving medications/supplements that were not ordered by the physician. The facility census was 52 residents, and the sample was 18. The deficient practice has the potential for the resident not receiving the appropriate treatment.

Findings include:

-Regarding Resident #24

Resident #24 was admitted on December 29, 2018, with diagnoses that included chronic embolism and thrombosis of left femoral vein, peripheral vascular disease, and type 2 diabetes mellitus with diabetic chronic kidney disease.

Review of the quarterly Minimum Data Set (MDS) assessment dated January 29, 2023 revealed a Brief Interview of Mental Status of 14, which indicated intact cognition.

Review of physician order's revealed an order dated July 14, 2022 for Herbal supplement Ocuprime supplement.

Review of physician orders revealed no evidence of orders for administration of Visifree supplement.

A medication observation was conducted on February 1, 2023 at 8:32 AM with a Licensed Practical Nurse (LPN/staff #112), who administered two Visifree capsules to resident #24.

-Regarding Resident #14:

Resident #14 was admitted on August 5, 2020 with diagnoses that included multiple sclerosis, major depressive disorder, and chronic kidney disease, stage 3.

Review of the quarterly MDS assessment dated January 30, 2023, revealed a Brief Interview of Mental Status of 15, which indicated intact cognition.

Review of physician orders revealed no evidence of orders for administration of Centrum Minis supplements or Florastar a probiotic supplement.

Further review of the physician orders revealed an order for Centrum Complete 18mg (milligram) - 400 mcg (microgram) dated October 1, 2021.

A medication observation was conducted on February 1, 2023 a registry LPN (staff #170), who administered one Centrum Mini and one Florastar capsule to resident #14.

An interview was conducted on February 1, 2023 at 1:19 PM with the Director of Nursing (DON/staff #113), who stated that the facility policy is to obtain a physician order for all medications prior to being administered. She stated that the provider will review medications that resident's order from the internet prior to administration. She reviewed resident #24's clinical record and stated that the resident orders supplements from the internet. She also stated that they do not have an order for the Visifree supplement. The DON also stated that regarding resident #14, that she was not sure that nursing had informed the provider that the resident provided his own medications, Centrum Minis and Floraster.

Further interview was conducted with the DON on February 1, 2020 at 2:19PM, who stated that after further clincial review, the Centrum Mini and Floraster did not have a physician order prior to administration for resident #14. She further stated that she reviewed the clinical record and that Centrum Complete and Centrum Minis are not the same formulary. There should have been a physician order for the administration of the Centrum Minis. She also stated that the Centrum Minis bottle had been opened in December of 2022, so had been administered since that time without a physician order. The DON stated that there was no order to administer Floraster. She stated that after review of resident #24's clinical record, that there was an order for a herbal supplement Ocuprime, but the formulary was not the same as Visifree. She further stated that there was no evidence of a physician order for Visifree and the medication should not have been administered. She also stated that this did not follow the facility policy, that all medications need a physician order prior to administration. She stated that risk would be that the physician would not be aware of the multivitamins the resident was taking.

An interview was conducted on February 2, 2023 at 9:06 AM with a Registered Nurse (RN/staff #119), who stated that it is the facility policy to follow physician orders as written, and to obtain physician orders, for all medications administered including nutritional and dietary supplements, vitamins, and minerals. She further stated that all medications need to be verified with physician review, including supplements, vitamins.

Review of the facility policy titled, Mediation and Treatment Orders, revealed that Medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state.

Based on observation, staff interviews, facility documentation and policy and procedures, the facility failed to maintain infection prevention and control during wound treatment for one resident (#32) per professional standards of practice.

Resident #32 admitted on August 8, 2018 with diagnoses that included dementia, psychotic disturbance, alzheimer's disease, and pressure ulcer of sacral region, stage 4.

Review of a care plan dated September 24, 2021 revealed the resident had a stage 4 pressure injury to sacrum.

Review of a quarterly Minimum Data Set (MDS) dated December 31, 2022, revealed a Staff Assessment for Mental Status score of 3, which indicated severe impairment. Further review revealed the resident had one unhealed stage 4 pressure ulcer.

Review of a physician orders revealed:
-Dated January 26, 2023 treatment to sacral wound apply collagen sheet and cover with sacral foam dressing. Change daily and PRN (as needed) for soilage.

An observation of wound care and treatment was conducted on February 1, 2023 at 10:27 AM, with an Licensed practical nurse (LPN/staff #118). The LPN washed her hands in the sink and entered the room, placing gloves on both hands. The LPN positioned the resident on her left side and removed the resident's brief. She proceed to remove the previous/old wound dressing, cleansed the ulcer with wound cleanser saturated 4x 4 gauze, opened the collagen dressing packet, and secondary foam dressing. The LPN then placed her gloved hand into her scrub and removed a felt tip pen from her scrub pocket. She wrote the date on the outside of the foam dressing, and replaced the pen into her pocket. The LPN applied the collagen dressing to the base of the wound, and covered with the secondary foam dressing. She removed the gloves, sanitized her hands, repositioned the resident and then entered the resident's bathroom and washed her hands. The LPN was not observed to remove her gloves and sanitize her hands after removal of the old dressing, and donn a clean pair of gloves prior to application of the new (clean) ulcer dressing.

An interview was conducted with the wound care nurse (LPN/staff #118) on February 1, 2023 at 1:58 PM. She stated that she uses one pair of gloves to remove and clean the wound, and then another clean pair of gloves to apply the new dressing. She stated that she did not do that during the wound care observation, and that this did not follow the facility process. The LPN stated that the risk could result in spread of infection.

An interview was conducted on February 2, 2023 at 2:26 PM with the Director of Nursing (DON/staff #133), who stated that she expected nurses to remove gloves and sanitize their hands after removing the old dressing, and to donn new/clean gloves prior to applying the new/clean dressing.

An interview was conducted on February 1, 2023 at 2:37 pm via the telephone with a Registered Nurse (RN, Wound Nurse/staff #115), who stated that the facility expectation for wound care treatments, includes donning a clean pair of gloves and removing the old/dirty dressing, removing the gloves, sanitizing hands and donning a clean pair of gloves prior to applying the new/clean dressing. She stated that nurses need to remove the gloves after removing to prior/old dressing because the dressing that is being removed is considered dirty. She further stated that that the nurse should not reach into her pocket for a pen without removing the gloves first, especially if she had used the same pair of gloves to remove an old dressing. She stated that the risk would be infection or exposing the wound to other organisms.

Review of the facility policy titled, Wound Care, revealed to put on exam glove and loosen tape and remove dressing, pull glove over dressing and discard into appropriate receptacle. Wash and dry hands thoroughly. Put on gloves, wash the wound, apply treatments as indicated.

Based on observations, staff interviews, and policy, the facility failed to ensure food items were food product were discarded on or before the expiration date in accordance with professional standards.

Findings include:

During a walkthrough of the kitchen conducted on January 30, 2023 at 9:35 am, with Director of Dining (staff #11) and Registerd Dietician (staff #117), multiple observations were made in the large refrigerator, freezer, and dry storage:

-a one-gallon container of onion and bell peppers mixture were observed in the walk-in refrigerator with approximately one half of the onion-peppers mixture remaining with a use by date of January 23, 2023.

During a walk-through in the kitchen conducted with the Director of Dining (staff #11) and Registerd Dietician (staff #117), were unable to state the last time the onions and pepper mixture used. Staff #11 stated the porter puts away orders, and takes out anything that is outdated. Director of Dining (staff #11) stated the porter did not follow the facility process for discarding outdated food and there is a possible risk of food borne illness if served to residents. The

An interview was conducted on February 2, 2023 at 09:24 AM with dietary porter # 52, who stated his role as porter for the warehouse is to make sure all produce is put away, rotated, label dry goods and produce, and for checking foods in fridge for their use by dates. He reported one of the first tasks he completes is checking dates and labels on refrigerated and storage items for expiration dates. He reported storage dates are three to five days. He also reported that he does not believe the onion pepper mixture had been used based on the menu, but stated if someone had eaten the expired food it could have resulted in illness. Staff #52 stated the Chefs are also responsible in checking dates on food items when he is not working in the facility.

An interview was conducted with Sous Chef (staff #101) on February 2, 2023 at 09:32 AM, who stated that he is in charge of the kitchen in the mornings. He stated everyone is responsible for ensuring foods are rotated and discarded when expired, and also making sure labels are dated. He stated julienned peppers would have been used during the weekend of January 28 or 29th for fajitas and could have been used for additional recipes. He reported the outcome of using the outdated peppers and onions could have definitely made someone sick if they were used after that date.

Further inverview was conducted on February 2, 2023 at 09:44 AM with the Chef (staff #19), who provided a menu for the week of January 22- January 28, 2023 and reported the pepper-onion mixture was not used in any of the recipes after the use by date. He also stated that if they were used after the use by date it could have resulted in foodborne illness through spoilage of product for anyone who would have eaten the peppers and onions.

Review of the facility policy titled, Food and Supply Storage, revealed that unused portions or open packages should be covered, labeled and dated. Discard food past the use-by or expiration date.