Every finding on record at Afton Oaks Nursing and Rehabilitation Center

Based on interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident # 2) of 6 residents reviewed for accidents hazards/supervision in that: The facility failed to ensure CNA A properly assisted Resident # 2 by performing a two-person bed mobility alone on 08/27/2026 at 10:10 a.m. This failure placed dependent residents at risk of experiencing pain, injuries, and lacerations which could result in diminished quality of life and hospitalization.Findings included: Record review of Resident #2's face sheet dated 05/18/2026 revealed he was a [AGE] year-old male admitted on [DATE] with the following diagnoses: hemiparesis (partial loss of movement on one side of the body), hypovolemia (when the body holds too much fluid), abnormal posture, generalized muscle weakness, atrial fibrillation (when blood flow is disrupted and causes abnormal fast heart beats) and heart failure (when the heart muscles cannot pump blood and oxygen effectively to meet the body's needs). Record review of Resident #2's MDS dated [DATE] revealed his BIMS was coded 11-indicating mild -to-moderate thinking and memory challenges. Functional abilities section revealed he was dependent on staff in: oral hygiene, toileting, shower, upper and lower body dressing, personal hygiene, rolling left and right, sitting to lying, lying to sitting. Record review of Resident #2's care plan dated 05/18/2026 revealed: Resident has an ADL self-care performance deficit. Goal: Will improve current level of function. Interventions: Assist with personal hygiene as required, bed mobility requires 2 staff for assistance. Goal: Resident will be free from falls. Intervention: Resident required 2-person assistance with bed mobility and positioning. In an interview with CNA A on 08/28/2026 at 11:18 a.m., she said she had completed peri care on Resident #2. She said the bed was in a low position. She said she was changing the linen , the resident turned and she assisted him in turning so she could securely change the linen. The resident rolled from the bed to the floor. Resident # 2 requested help from the floor, but CNA A told him she needed help and he would be assessed on the floor before staff could assist him back in bed. She said Resident # 2 hit his head and was bleeding. CNA A said Resident #2 was communicating with staff and when the paramedics arrived, he told them he fell. CNA A said she did not know Resident # 2 was a two person assist. She said after the incident that was the first time she saw a Kardex (a centralized documentation system). She said in the past the nurses told her which residents required 2 persons assistance. She said on that day the nurse did not tell her, but that was not the first time she cared for Resident #2.In an interview with LVN A on 08/28/2026 at 1:15 p.m., she said she was the primary nurse for Resident #2 on 08/27/2026. She said CNA A did not ask her for assistance. She said she assessed the resident and 911 was called. She said she was called to Resident #2's room where she observed the resident on the floor on his left side. She said the resident was communicating with staff. She said that was the first time she cared for the resident. LVN A said she expected CNA A to have called for assistance. She said she did not know Resident #2 required 2 staff assistance which was why she did not tell CNA A. LVN A said she knew the resident was a 2-person assist after the fall. She said she failed to refer to the Kardex on the day Resident #2 fell. LVN A said the risk of her not referring to the Kardex where she would get information on how to provide care was the fact that care was not provided effectively. In an interview with RN A on 08/28/2026 at 3:50 p.pm., she said it was the responsibility of the nurses to update the CNAs on the assistance type for all residents. She said if the nurses did not update the CNAs there was a risk of a resident falling, they might hit their head which could result in hospitalization. In an interview with the ADON on 08/28/2026 at 4:20 p.m., she said the CNAs had access to the Kardex and were trained to use the Kardex which was where they looked up the required assistance level for all residents. She said Resident #2 was communicating with staff after the fall and waved at her when the paramedics picked him up. In an interview with the DON on 08/28/2026 at 4:30 p.m., she said the CNAs were trained by the DON and the ADON during new employee orientation on the use of the Kardex that would show the assistance level and if any special required care for the residents. She said the facility had continuous competency and as needed in-services. She said CNA A was trained on where to obtain information prior to resident care. The DON said, if CNA A had told her she did not know, she would have reeducated her with a return demonstration. In an interview with the ADM on 08/28/2026 at 5:10 p.m., she said the CNAs knew where to look up the information on how to care for residents. Record review of facility's undated document titled: Fall Policy, stated: Appropriate education will be provided to all staff members as needed on fall prevention.

Based on interview and record review the facility failed to immediately notify the resident's representative when there was a significant change in the resident's physical and psychosocial status and when there is a decision to transfer or discharge the resident from the facility for 1 (Resident #1) of 6 residents reviewed for change in condition and RP notification in that: The facility failed to ensure LVN B notified the resident's responsible party within a reasonable time when Resident # 1 was transferred to a hospital on [DATE].This failure could place residents at risk of not having their responsible party representing them in care decisions, which could result in a delay in treatment and a decline in condition. Findings included: Record review of Resident #1's face sheet dated 07/06/2026 revealed she was a [AGE] year-old female admitted on [DATE] with the following diagnoses: pulmonary disease (that affects the lungs and breathing) , diabetes (blood sugar level irregularities) schizophrenia (mental health disorder that affects how a person thinks, feels and behaves) , heart failure (when the heart muscles cannot pump blood and oxygen effectively to meet the body's needs), anxiety, traumatic brain disfunction (disruption in normal brain function) and communication deficit. Record review of Resident #1's MDS dated [DATE] revealed a BIMS was scored 07-indicating severe thinking. Section D0700-social isolation -always. Record review of Resident #1's care plan dated 03/20/2026 revealed: Impaired cognitive function thought process related to dementia. Goal: Will communicate basic needs on a daily basis. Interventions: Ask yes/ no questions to determine resident's needs, use the resident's preferred name and make eye contact when speaking. Communication problem related to dementia. Goal: Will maintain communication function. Interventions: Be conscious of resident's position when in group and activity room to promote proper communication with others and monitor non-verbal indicators of discomfort or distress and follow-up as needed. Anticonvulsant related to schizophrenia. Goal: Will maintain or improve behavior problems. Intervention: Inform the physician for any adverse effects and behavioral symptoms, increase and changes. Mood problem related to major depression. Goal: Will have improved mood state. Intervention: Monitor/record/report to Physician acute episode feelings or sadness, loss of pleasure, feeling of worthlessness, change in sleep pattern. Record review of Resident #1's progress note dated 06/27/2026 at 10:01 a.m., revealed the RP called to inquire about the resident. The RP was told the resident was hospitalized for behavioral reasons. That made the RP angry. In an interview with LVN A on 08/28/2026 at 1:15 p, m., she said it was the responsibility of the nurse who sent out Resident #1 to the hospital to have notified the family of the resident's location and why the resident was sent out. She said if that was not done the family would not know where the resident was. LVN A said delayed notification could affect the resident because she could feel depress and lonely as she would not have family visitations. In an interview with RN A on 08/28/2026 at 3:50 p.m., she said it was the responsibility of the nurse who cared for the resident on the day she was sent to the hospital to have notified the family. She said the family had the right to be notified with any updates. She said if the facility did not then the facility was liable. In an interview with the ADON on 08/28/2026 at 4:20 p.m., she said it was the responsibility of the facility to notify the families when residents were sent out for treatment and when they return. She said if Resident #1's family was not notified they would not know the new location. The ADON said if she knew that the family was not notified, she would have had a one-to-one discussion with the nurse involved and completed an in-service.In an interview with the DON on 08/28/2026 at 4:30 p.m., she said with a change in condition she expected the nurses to have notified the physician, the POA and the RP. She said if Resident #1's family was not notified; the family would not know the resident's location. She said the failure could impact the resident's healing process and delay hospital care if the Physician at the hospital needed family signature for treatment. The DON said LVN B was the nurse who cared for Resident #1 on the day she was transferred to the hospital. The DON said LVN B was on leave. A telephone call to LVN B on 08/31/2026 at 4:06 p.m., was unsuccessful. In an interview with the ADM on 08/28/2026 at 5:10 p.m., she said she expected the nurse who took care of Resident #1 to have informed the family that the resident was transferred to the hospital for a higher level of care. Record review of facility's undated document titled: Notifying the Physician of Change in Status revealed: The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise.

Based on observations, interviews, and record reviews, the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 20% based on 5 errors out of 25 opportunities, which involved 5 of 5 residents (Resident #3, Resident # 48, Resident #28, Resident #64 and Resident #51) reviewed for pharmacy services. The facility failed to ensure MA A accurately verified and administered Hydralazine 25mg as per physician's order for Resident #51. The facility failed to ensure MA B properly verified and administered timely manner as per physician's order. The facility failed to ensure MA C properly verified and reordered Sevelamer Carbonate 800mg from pharmacy in a timely manner for Resident #3 The facility failed to ensure LVN D properly verified and administered 20 units insulin Novolog at 7:00 am in a timely manner as per physician' order for Resident #64 These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.Findings include: - Record review of Resident #51's face sheet dated 06/10/2026, revealed a [AGE] year-old male admitted to facility on 04/01/2026. Resident #51 had diagnoses which included essential hypertension (high blood pressure that is not caused by another specific medical condition) Record review of Resident #51's Comprehensive MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 15 indicating Resident #51's cognitive function and memory was intact. Record review of Resident #51's care plan with date initiated on 04/20/2026, revealed Resident #51 had hypertension with interventions to give anti-hypertension medication as ordered and to monitor side effects such as increased heart rate. Record review of Resident #51's physician order dated 06/10/2026, revealed an order for Hydralazine HCL 25mg - give 1 tablet by mouth three times a day for hypertension with a start date of 04/29/2026. During medication observation on 6/09/2026 at 8:23 am, MA A took Resident #51's blood pressure and dispensed the following medications: Carvedilol 25mg - 1 tablet, Metformin 500mg - 1 tablet, Losartan 100mg - 1 tablet, Baclofen 10mg - 1 tablet, Hydrochlorothiazide 25mg - 1 tablet, docusate sodium 100mg - 1 tablet, magnesium oxide 400mg - 1 tablet, Senna 8.6 mg - 1 tablet. MA A stated she did not have Eliquis 2.5 mg - 1 tablet and Potassium Chloride 20 mEq - 2 tablets in her cart. MA A searched the overstock drawer and stated Resident #51 did not have an additional blister pack for those 2 medications. MA A requested ADON J to retrieve these 2 medications from the facility's emergency kit. Upon receiving these 2 medications from the emergency kit, MA A administered the above dispensed medications to Resident #51 and stated she completed administering Resident #51's morning medication. During an interview on 06/09/2026 at 8:35am, MA A stated she was unsure why Resident #51 did not have Eliquis 2.5 mg and Potassium Chloride 20 mEq in the cart. MA A stated she was new to the position and that it was her first day on the medication cart. MA A stated she would call pharmacy to find out when it was reordered and when it would be delivered. Record review of Resident#51's physician order and MAR on 6/09/2026 at 11:15 am, revealed MA A did not administer Hydralazine 25mg during medication observation. Record review further indicated that MA A administered this medication to Resident #51 later after medication observation was completed. Record review of Resident #64's face sheet dated 6/10/2026, revealed a 73- year- old man admitted to facility on 04/05/2024. Resident #64 had diagnoses which included Type 2 Diabetes Mellitus (a condition where the body either resists the effects of insulin or doesn't make enough insulin) Record review of Resident #64's Comprehensive MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 9 indicating Resident #64's cognitive function is moderately impaired. Record review of Resident #64's care plan with date initiated on 04/11/2024, revealed Resident #64 had Diabetes Mellitus with interventions to give diabetic medication as ordered and to monitor for side effects and effectiveness. Record review of Resident #64's physician order dated 06/10/2026, revealed an order for insulin Aspart Flex Pen Subcutaneous Solution Pen-Injector 100units/ml - Inject 20 units subcutaneously three times a day for diabetes; hold if glucose is below 110 with a start date of 01/16/2026. During medication observation on 06/09/2026 at 9:00 am, LVN D, performed a blood glucose check for Resident # 64 who had finished eating his breakfast. Blood glucose level was recorded as 192. Observation of the EMAR revealed this medication was red in color indicating it was past due. Further observation revealed that this insulin was supposed to be administered at 7am as per physician's orders. LVN D prepared 20 units of Novolog Flex Pen Insulin Asparte and administered insulin to Resident #64's right lower quadrant area of the abdomen. During an interview on 6/09/2026 at 9:05 am, LVN D stated Resident #64 was supposed to receive insulin injections between 7 am and 8 am. LVN D stated it was his third day on the job after two days of training. LVN D stated that the computer and the internet were slow. LVN D stated if Resident #64 did not get his insulin on time, Resident #64 could potentially go into insulin crisis. LVN D stated if Resident #64's blood glucose was too high; it could affect Resident #64 negatively. During an interview on 06/09/2026 at 12:25 pm, the VP of Clinical Services reviewed Resident # 64's insulin injection timing in EMAR and stated Resident #64 had received his next 20 units of Novolog insulin injection at 11:15 am with a blood glucose level at 232. VP of Clinical Services stated Resident # 64 could become hypoglycemic (low blood sugar) if insulin doses were administered too close. VP of Clinical Services stated he would monitor Resident #64's blood glucose level closely since the MD did not give orders to hold the insulin dose. Record review of Resident #28's face sheet dated 6/10/2026, revealed a 73- year- old man admitted to facility 06/28/2023. Resident #28 had diagnoses which included Glaucoma (eye disease that damages the optic nerve Record review of Resident #28's Quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 12 indicating Resident #28's cognitive function is moderately impaired. Record review of Resident #28's care plan with date initiated on 11/30/2023, revealed Resident #24 has potential impairment to visual function related to Glaucoma with interventions to administer medication as per MD orders and to observe for side effects and effectiveness. Record review of Resident #28's physician order dated 06/09/2026, revealed an order for Refresh Tears Ophthalmic Solution 0.5% - give 1 drop to both eyes every 12 hours for dry eyes with a start date of 12/24/2025. During medication observation on 06/09/2026 at 9:25am, MA B prepared 1 vial of Refresh Plus Eye Lubricant 0.5% for Resident #28. Observation of the EMAR revealed the medication was red in color indicating it was past due. MA B stated this medication was scheduled to be given at 8am. MA B administered 1 drop of the Refresh eye drop into each of Resident #28's eyes by pulling his upper eyelid up and instilling it into his eyes. During an interview on 06/09/2026 at 9:30 am, MA B stated she was unsure of the right way to administer eye drops. MA B stated the internet was slow, causing delay in administering the eye drops timely. Record review of Resident #48's face sheet dated 6/10/2026, revealed a 50- year- old man admitted to facility 04/07/2026. Resident #48 had diagnoses which included Paraplegia (the loss of movement and feeling in the lower half of your body, usually affecting both legs, the pelvis, and sometimes the stomach) and Chronic Pain Syndrome (on going pain condition that last longer than normal healing time) Record review of Resident #48's Comprehensive MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 14 indicating Resident #48's cognitive function and memory was intact and normal. Record review of Resident #48's care plan with date initiated on 04/13/2026 revealed Resident #48 has paraplegia with interventions to give medications as ordered and to monitor / document side effects and effectiveness. Record review of Resident #48's physician order dated 06/10/2026, revealed an order for Gabapentin Oral tablet 600mg - give 1 tablet by mouth four times a day for Neuropathy (nerve damage) with a start date of 04/04/2026. During medication observation on 06/09/2026 at 10:07 am, MA B prepared to administer medications for Resident #48. Observation of the EMAR revealed Gabapentin 600mg was red in color indicating it was past due. This medication was scheduled for 8am. MA B took Resident #48's blood pressure which read 111/64. Resident #48 denied having any pain. MA B dispensed the following medication: Magnesium Oxide 400mg - 1 tablet, Multivitamin with Minerals - 1 tablet, Gabapentin 600mg - 1 tablet, Digoxin 0.125mg - 1 tablet, Furosemide 40mg - 1 tablet, Buspirone 10mg - 1 tablet, Eliquis 5mg - 1 tablet, Carvedilol 3.125mg - 1 tablet, Sertraline 25mg - 1 tablet, Lisinopril 5 mg - 1 tablet, Alprazolam 0.5mg - 1 tablet. MA B administered these medications to Resident #48 and stated she completed administering Resident #48's morning medication. During an interview on 06/09/2026 at 10:23 am, MA B stated Resident #48 should have received his medication between 8am and 9am. MA B stated delaying this medication could potentially cause Resident #48 to be in pain. MA B stated giving this medication late could bring it closer to the next upcoming dose. During record review and interview on 06/09/2026 at 12:15 pm, LVN E stated MA B should administer medications in a timely manner, and should notify her nurse of any out of compliance. LVN E stated if a medication was administered late, it may run into the timing of the next dose and may cause adverse effects to residents. LVN E stated she would notify MD of Resident #48's out of compliance for medication Gabapentin 600mg. Record review of Resident #3's face sheet dated 6/10/2026, revealed a 60- year- old man admitted to facility 04/07/2026. Resident #3 had diagnoses which included End Stage Renal Disease (permanent kidney failure). Record review of Resident #3's Comprehensive MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 6 indicating Resident #3's cognitive function and memory was severely impaired. Record review of Resident #3's care plan with date initiated on 04/20/2026 revealed Resident #3 needed dialysis related to stage 5 chronic kidney disease or end stage renal disease with interventions to monitor labs and report to doctor as needed. Record review of Resident #3's physician order dated 06/10/2026, revealed an order for Sevelamer Carbonate Oral tablet 800 mg - give 1 tablet by mouth three times a day related to .stage 5 chronic kidney disease or end stage renal disease. During medication observation on 06/09/2026 at 12:35pm, MA C prepared to administer medication for Resident #3. MA C stated the medication Sevelamer Carbonate 800mg scheduled for 1:00 pm was not available in her cart. MA C stated she administered the last pill from the blister pack during morning medication pass. MA C requested LVN H retrieve the said medication from the facility's emergency kit. Upon checking, LVN H stated she was unable to retrieve the said medication from the emergency kit due to pharmacy requiring authorization from the insurance company. LVN H stated this medication was supposed to be ordered by the dialysis team. LVN H notified the MD immediately and received instructions to hold this medication until further notice. During an interview on 06/09/2026 at 12:40 pm, MA C did not respond when asked why the medication was not ordered a few days sooner to prevent Resident #3 from missing a dose. MA C stated she had placed the order 06/09/2026 morning to the pharmacy and was expecting this medication to be delivered later this evening. During an interview on 6/09/2026 at 9:35 am, ADON F stated that when administering eye drops, MA B should pull the eye lids down and instill the eye drop in the lower sac. ADON F stated the tip of the eye drop should be away from the eyeball. ADON F stated it was important to administer insulins timely. ADON F stated diabetic residents should get their insulin before breakfast. ADON F stated Resident #64 could become hyperglycemic (high blood sugar) and could affect resident when the blood glucose goes up. ADON F stated she would assess Resident #64 and notify MD regarding this out of compliance status During an interview on 06/09/2026 at 12:52pm, the VP of Clinical Services stated that the nursing managers will audit all dialysis residents on Sevelamer Carbonate who were unable to obtain this medication from pharmacy, will ensure there was enough medication in house and will proceed to reorder medications 7 days out. During an interview on 06/11/26 at 10:44am, the DON stated her expectation was for nurses and MAs to reorder medications before it runs out, stock the medication cart appropriately, and make sure nurses and MA were following the rights of medication administration. DON stated it was important that the nurses and MA were administering the medication on time. DON stated MAs should notify their nurses immediately so that nurses could reach out to providers for further instructions. DON stated the nursing management team would do an in-service on medication administration and complete a medication error assessment. Record review of the facility's policy titled PCU018 - Medication Administration and General Guidelines P&P; v3-2025 read in part .Procedures: #9. At the end of each medication pass, the person administering the medication reviews the MAR to ascertain that all necessary doses were administered and documented. Checklist for completing proper steps in the administration of medication: Adheres to the 6 rights of medication Administration: . #5) Right Time.

Based on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. -The facility failed to ensure their stove pilot light was working properly, on 6/8/26, causing natural gas to flow into the kitchen and dining room area. --The facility failed to ensure [NAME] E used proper hand hygiene while preparing food items. On 6/9/26, [NAME] E did not remove her gloves and perform proper hand hygiene after cleaning kitchen countertops, obtaining ice from the ice machine, retrieving cooking utensils from the floor and drawer, then preparing the resident's lunch.-The facility failed to ensure two juice dispenser tubes were kept off the floor on 6/8/26. -The facility failed to ensure a large container of thickener had two conflicting labels on 6/8/26. -The facility failed to ensure the menu posted near the dining room on 6/8/26 accurately reflected the meal that was served. This failure could place residents who ate the food from the kitchen at risk for food-borne illness.Findings include:An observation and interview of the facility's kitchen on 6/8/26 between 9:12am and 9:22am revealed the following: -There was a strong natural gas odor in the kitchen. When asked about the odor, the Dietary Manager stated the odor was probably coming from the convection oven because the door was open. The Dietary Manager closed the convection oven door. -There was a large tub of a white granulated substance on the countertop. There was a sticker that read, cornmeal on the tub. There was another sticker on the opposite side of the tub that read, thickener. When asked about the stickers, the Dietary Manager stated the tub contained thickener. He said the sticker that said cornmeal should be soaked off. -There were 6 boxes of juice stacked on a cart near the floor. Each box had a tube that ran from the box to the drink dispenser head above the boxes of juice. Two of the six tubes were touching the floor underneath the cart. In an observation on 6/8/26 at 10:32am, there was a natural gas odor in the dining room. There was a large group of residents seated in the dining room participating in an activity. In an interview on 6/8/26 at 10:40am, the Administrator stated she was not aware of the natural gas smell. She said it had not been a problem before and this was the first time she had heard about it. She said she would call the local natural gas company. In an interview on 6/8/26 at 11:28am, the Maintenance Director stated he checked in the kitchen for the natural gas odor. He said the back-right stove pilot (a small, constantly burning gas flame that serves as a continuous ignition source for the main burners) was on, but it was not lit. He said without the flame, the gas leaked into the air. Surveyor asked if it was functional, and the Dietary Manager turned the back-right burner on and off to show that it was functional. In an observation and interview on 6/8/26 at 11:30am, the local gas company representative tested for a gas leak near the stove. He stated the kitchen was safe. In an observation on 6/8/26 at 12:11pm, the menu posted near the dining room entrance was dated 6/4/26. The meal that was listed for lunch was pot roast with red potatoes, baby carrots and a dinner roll. In an observation on 6/8/26 at 12:11pm, the residents in the dining room were served sloppy joes, potato salad, and baked beans. During observation on 06/09/2026 at 11:10 a.m., [NAME] E cleaned countertops with white towel while wearing gloves. She then opened the ice machine, grabbed a scoop and began to retrieve ice from the machine and placed it in a Styrofoam cup. At 11:14 a.m., she utilized cooking tongs that were sitting on top of the kitchen counter and flipped chicken in the deep fryer. At 11:15 a.m. [NAME] E dropped a knife on the floor and then picked up knife from floor, while still not changing her gloves. Gloves were located on the preparation counter near the sink. At 11:17 a.m., she began washing dishes with same gloves and opened a box of plastic wrap then applied to food that was being served for lunch. At 11:18 a.m., she again flipped chicken in the deep fryer then retrieved food basket liner from a drawer and applied it to pan. At 11:19 a.m., she retrieved chicken out of fryer, while still not replacing her gloves nor washing her hands. At 11:26 a.m., [NAME] E took off gloves, however, failed to wash her hands. Interview on 06/09/2026 at 2:52 p.m., with DA N said that gloves were expected to be changed after working on each kitchen cart. She stated that she cleans the kitchen counters when they appear dirty, but changes her gloves and washes her hands because it is not safe. DA N stated that once used gloves are nasty, and they're supposed to take them off and wash their hands. In a telephone interview on 6/9/26 at 5:39pm, [NAME] V said she assisted with preparing breakfast on Monday, 6/9/26. She said she did not smell a natural gas odor. She said had smelled natural gas in the past, but it happened a while ago. She said when there was a natural gas smell, it meant they needed to relight the pilot. She said she would notify the Maintenance Director immediately. She said they did not turn the gas off so the pilot stayed lit. She said the knob on the front will turn on the gas. When asked if they monitored the pilots, she said when they were cooking and noticed the pilot was off or if they smell gas, they would notify the Maintenance Director. In an interview on 6/11/26 at 10:53 a.m., the Dietary Manager said that staff were expected to change their gloves and perform hand washing when moving from one section of the kitchen to another. He said there is a risk for cross contamination and infection control when proper hand hygiene is not followed. Dietary Manager stated that his last in-service for handwashing, gloves, and PPE in the kitchen was completed on 04/21/2026. When asked about the natural gas odor on Monday, the Dietary Manager said it was possible that the oatmeal or grits boiled over, causing the pilot light to turn off. He said it did not happen very often and if the staff noticed it or they smelled natural gas, they would notify maintenance personnel immediately. He said they started cooking breakfast on 6/9/26 around 7:30am. He said the risk of the pilot light going out like was we could explode. When asked about the menus that were posted for the residents, he said after morning meeting, he posted the daily menu on the wall. He said on the weekends, the cooks were required to change the menu daily. He said they must have forgotten to change them. When asked about the juice tubing on the floor, he said he was not aware that it was a problem. When asked about the tub of thickener that had two conflicting labels on it, the Dietary Manager said he did not think that a cook would use thickener in place of cornmeal due to the tub being mislabeled. Interview on 06/09/2026 at 3:00 p.m., [NAME] E said that it was important to keep the kitchen clean and sanitized to prevent airborne illnesses and cross contamination. She stated that it was expected for staff to wash their hands every time they touched something. When asked what prevented her from changing gloves and proper hand-washing during the observation, [NAME] E stated she was focused on making sure her job was done. She stated that proper hand-washing is important to prevent cross contamination and residents can be exposed to germs if it is not done. [NAME] E stated she received training on this subject approximately three months ago. Record review of the facility's Dietary Glove Standard Protocol dated 04/09/25 read in part .6. A scoop or tongs will be used when handling ice. If gloves are used, the ice will be transferred to a bowl using a scoop or tongs, and the ice will be transferred from the bowl to glasses using a gloved hand, that has been washed before and after glove use.careful hand washing by personnel will be done.between handling of dirty dishes, boxes, or equipment and handling clean food or utensils.Record review of the facility's policy regarding Food Storage and Supplies dated 2012 read, Dry bulk foods. are stored in seamless metal or plastic containers with tight covers or bins which are easily sanitized. Containers are labeled. Record review of the facility's policy regarding Maintaining a safe, functional environment (undated) read, .Interior spaces will meet the needs of the resident population and are safe and suitable for the care, treatment and services provided. The facility keeps furnishings and equipment safe and in good repair. Furnishings and equipment in need of repair shall be reported to the Maintenance Department.

Based on observation, interviews, and record reviews, the facility failed to establish accurate acquiring, dispensing and administering of controlled medications and a system of accurate medication records that enabled periodic reconciliation and accounting of all controlled medications to meet the needs of 1 of 4 residents (Residents #61) reviewed for pharmacy services. The facility failed to ensure that controlled drug records were accurate for Resident #61 and that an account of all controlled drugs was maintained and periodically reconciled. The facility failed to ensure controlled medication for discharged Resident # 5 and Resident #76 on 300 B Hall Nurse's cart were removed within 3 days upon their discharge from facility. The facility failed to ensure discontinued medications for Resident # 31, Resident #56, and Resident #36 were removed from 300 B Hall nurse's cart. This failure could result in drug diversion, place residents at risk of receiving discontinued medication and residents' medications not being available.Findings include:- Record review of Resident #61's face sheet dated 6/11/2026, revealed a [AGE] year-old man admitted to facility on 07/12/2013. Resident #61 had diagnoses which included cerebral infarction (blood vessel in the brain becomes blocked causing a stroke) and unspecified convulsions (sudden uncontrollable episode of rapid or violent muscle spasm) Record review of Resident #61's Quarterly MDS assessment dated [DATE], section C (Cognitive Patterns) revealed a BIMS score of 3 indicating Resident #61's cognitive function and memory is severely impaired. Record review of Resident #61's care plan with date initiated on 03/20/2019 revealed Resident #61 has seizure disorders (sudden uncontrollable episode of rapid or violent muscle spasm) with interventions to give medications as ordered and monitor for effectiveness and side effects; obtain and monitor lab/diagnostics as ordered. Record review of Resident #61's physician order dated 06/11/2026, revealed an order for Vimpat Oral Solution 10mg/ml (Lacosamide) - give 20 ml by mouth two times a day for seizures with renewed order dated 6/10/2026. During observation of 300 B Hall Nurse's cart on 06/09/2026 at 3:03pm with LVN E and RN K, the following controlled medication was kept in the locked box: Resident # 5's Hydromorphone 4mg - 6 pills remaining, Hydromorphone 2mg - 3 pills remaining, Morphine Sulfate 60mg - 19 pills remaining, Resident # 76's Tramadol HCL 50mg with - 41 pills remaining in blister pack #1 and 22 pills remaining in blister pack #2. LVN E stated Resident #5 was sent to the hospital on [DATE] and Resident # 76 was discharged on 5/31/2026. Further observation revealed Resident #31's Hydroxyzine 25mg - give 1 tablet PRN for 14 days issued on 04/30/2026; Resident #56's Triamcinolone 0.5% cream issued on 04/16/2026 and discontinued on 04/24/2026. Resident #36's Ammonia Lactate 12% lotion with issue date 08/12/2025. RN K stated Resident #36 had not used the Ammonia Lactate lotion in a while. During a controlled drug count observation of 300 B Hall nurse's medication cart on 06/09/2026 at 3:30pm with LVN E and RN K, Resident #61's controlled medication Lacosamide Solution 10mg/ml revealed a discrepancy in the actual amount remaining in the bottle versus amount written in controlled substance record sheet. Resident had 4 bottles of Lacosamide Solution. Bottle #1 and #2 had 400ml each, bottle #3 had 200ml and bottle #4 had 75ml. Controlled substance record sheet revealed on 06/05/2026 at 9pm 1200ml was received from pharmacy signed by ADON J. 20ml was dispensed on 06/07/2026 at 8am - with amount remaining 1180 ml; 20ml was dispensed on 06/07/26 at 8pm - with amount remaining 1160 ml; 20ml was dispensed on 06/08/2026 at 8am - with amount remaining 1140 ml; 20ml was dispensed on 06/08/2026 at 8pm - with amount remaining 1120 ml and 20ml was dispensed on 06/09/2026 at 8am - with amount remaining 1100 ml. The actual cumulative amount remaining in the 4 bottles were 1075ml - a discrepancy of 25 ml. RN K immediately notified DON. During an interview on 06/09/2026 at 3:20 pm, LVN E stated controlled medications should be turned in to DON once a resident was no longer at the facility. LVN E stated she was unsure how soon it should be turned in, but normally it was the day of or the next day. LVN E stated sometimes the controlled medications are kept in the cart 4 to 5 days after a resident is discharged to the hospital because they might return soon. During an interview on 06/09/2026 at 3:40 pm, ADON F verified the controlled substance record sheet against the actual remaining amount in the bottles and confirmed there was a discrepancy of 25 ml. ADON F stated an investigation would be initiated immediately. ADON F stated nurses should document the actual amount remaining in the bottle instead of simply subtracting the number written in the controlled substance record sheet. During an interview on 06/09/2026 at 3:50pm, LVN E stated she dispensed and administered 20ml of this medication to Resident #61 at 8am on 06/09/2026. LVN E stated she believed she dispensed the correct amount but stated she failed to verify the actual amount remaining in the bottle. LVN E stated she subtracted 20ml from the remaining amount written on the controlled substance record sheet and wrote the new remaining amount on the sheet. LVN E stated it was not best practice and that she should have looked at the actual amount remaining in the bottle each time she dispensed and documented on the controlled substance record sheet. During an interview on 06/09/2026 at 3:35pm, RN K stated discontinued or discharged medications should not be kept in the medication cart. RN K stated that the discontinued or discharged medications should be placed in the Discharge Medication bin which was in the 300 Hall medication storage room. RN K stated discontinued controlled drugs should be returned to DON immediately. RN K stated if discontinued medications are not removed from the cart, it may result in medication error or drug diversion. RN K stated carts should be audited daily. During an observation of 300 B Hall MA cart on 06/09/2026 at 4:10pm with MA B, the following medications remained in the cart:- Resident #31's Latanoprost Solution 0.005% issued on 01/02/2026 with instructions from pharmacy to discard medication 42 days after 1st use - bottle had a written date as 8/27; Resident # 44's Latanoprost Solution 0.005% issued on 03/26/2026 with instructions from pharmacy to discard medication 42 days after 1st use - bottle opened on 03/30/26; and another bottle of Latanoprost Solution 0.005% issued on 03/02/2026 with instructions from pharmacy to discard medication 42 days after 1st use - bottle opened on 03/05/26; During an interview on 06/10/2026 at 10:31am, the DON stated she did not suspect drug diversion. DON stated the nurses could be overpouring slightly more than 20ml when dispensing this medication. DON stated the nurses were probably not paying close attention to the calibrated line on the pill cup to accurately dispense 20ml. DON stated the nurse managers will audit and monitor controlled drugs dispensed to make sure the nurses are pouring the right amount and reading the calibrated line of the pill cup at eye level for accuracy. DON stated an in-service on medication administration and management will be provided. DON stated Resident #61 could experience elevated lab levels if the correct amount was not administered. DON stated routine labs were drawn for residents who are on seizure medications. On 6/10/26 at 1:30pm, DON stated a self-report was filed with Texas Health and Human Services for the controlled drug discrepancy identified on 06/09/2026 during medication cart observation. Record review of Resident # 61's MAR on 06/11/2026 at 2:40pm revealed Lacosamide Solution 10mg/ml was administered at 8am and 8pm on 06/09/2026 and 06/10/2026, and at 8am on 06/11/2026. During an investigation of the self-report for Resident #61 on 06/11/2026 at 2:35pm, the controlled substance record sheet and the medication were reviewed with ADON F. It was discovered there were further discrepancies of Lacosamide Solution 10mg/ml for Resident #61. The actual remaining amount in the bottles were 1025 ml versus the remaining amount written on the controlled substance record sheet was 995ml - a surplus of 30ml. The controlled substance record sheet indicated that on 06/09/2026 at 8pm - 20ml was dispensed with remaining amount of 1055ml; 20ml was dispensed on 06/10/2026 at 8am - remaining amount 1035ml, 20ml was dispensed on 06/10/2026 at 8pm - remaining amount 1015ml, 20ml was dispensed on 06/11/2026 at 8am - remaining amount 995 ml. During an interview on 06/11/2026 at 2:45pm with LVN E and ADON F, LVN E stated she administered the last dose at 8am on 6/11/2026 and made sure she measured accurately to dispense 20 ml. LVN E stated she after she had administered the medication, she did not write the amount on the sheet immediately. LVN E stated she wrote the amount on the sheet while it was being reviewed by ADON F. LVN E stated she should have written the amount on the sheet immediately upon dispensing the medication. LVN E stated she wrote the amount 995ml after subtracting 20ml from the last written amount on the sheet. ADON F stated she was not sure how there was a discrepancy again, but in a surplus amount. ADON F stated the nurses are subtracting the amount on paper and not looking at actual amount in bottles. ADON F stated LVN E should write neatly and legibly on the controlled substance record sheet to avoid errors and discrepancies. ADON F stated she will notify the DON and will continue to investigate, provide in-service and observe medication administration for nurses and MA. Record review of facility's policy titled PCU019 - Controlled Medications - Administration (revised 04/06/2026), P&P, v3-2025 read in part .Procedures: #6) when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: date and time of administration; amount administered; signature of the nurse administering the dose, completed after the medication is actually administered. #8) At shift change, a physical inventory of all the controlled medication is conducted by two licensed nurses and/or one nurse and a CMA.

Based on interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 19 Residents (Resident #82) reviewed for care plans. -The facility failed to develop and implement a care plan regarding Resident #82's history of suicidal ideations. This failure could place residents at risk of not having their needs met or inability of staff to identify a change of condition.Findings Included:Resident #82Record review of Resident #82's admission Record generated on [DATE] revealed Resident #82 was admitted to the facility on [DATE] with diagnoses of sepsis (the body's extreme, life-threatening response to an infection), schizophrenia (a complex, chronic brain disorder that impairs a person's ability to interpret reality, causing hallucinations, delusions, and disorganized thinking) and schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia, like hallucinations or delusions, with a mood disorder, like depression or bipolar disorder). She was [AGE] years old. Record review of Resident #82's admission MDS assessment dated [DATE] revealed she had a BIMS score of 9, indicating she had moderate cognitive impairment. She had a PHQ-9 (a standard 9-question self-report tool used by healthcare professionals to screen, diagnose, monitor, and measure the severity of depression) score of 9, indicating she had minimal symptoms of depression. She was assessed as having thoughts that you would be better off dead, or of hurting yourself in some way 12 to 14 days in the last two weeks, or nearly every day during the lookback period (the time period during the assessment process). Record review of Resident #82's care plan dated [DATE] revealed the following focus and interventions: - Resident #82 required antidepressant medication for a diagnosis of depression. Interventions included educating the resident about risks, benefits and the side effects of medication, give antidepressant medication as ordered by the physician, monitor for side effects including suicidal ideations, and monitor and report to the physician for signs and symptoms of depression unaltered by antidepressant medications, including sadness, irritability and anger. Further record review of Resident #82's care plan dated [DATE] revealed it did not indicate that she had a history of suicidal ideations and did not include interventions to prevent suicidal ideations or attempts. Record review of Resident #82's Social Service Note dated [DATE] at 12:26pm, revealed Social Worker A wrote that she spoke to the resident to complete the BIMS assessment. Resident stated she had suicidal ideations. She stated she wanted to die. She stated she had a plan and would stab herself in the stomach with a knife. Record review of Resident #82's Transfer Notification Note dated [DATE] at 6:39pm indicated she was transferred to a hospital related to a behavioral issue. Record review of Resident #82's Nursing Note dated [DATE] at 7:23pm revealed she was readmitted to the facility from a behavioral hospital. Record review of Resident #82's Outpatient Psychiatry Progress Note dated [DATE] at 2:23pm revealed she was seen by Psychiatric NP B via telemedicine. Psychiatric NP B wrote, During today's telehealth encounter, the resident appeared acutely emotionally distressed, disorganized, and preoccupied with death-related statements. The resident repeatedly stated, 'I will die,' and referenced deceased family members. Staff present during the visit expressed significant concern regarding the resident's worsening mental status and behavior. During the evaluation, the resident was observed holding a table knife obtained from her lunch tray. Staff were immediately instructed to remove the object and maintain close supervision. The resident's presentation is concerning for active suicidal ideation with plan, impaired judgement, emotional instability and acute psychiatric decompensation despite recent hospitalization. Given the severity of symptoms and ongoing safety concerns, the resident is assed to be at high acute risk for self-harm and requires a higher level of psychiatric care for stabilization. Record review of Resident #82's Transfer Notification dated [DATE] at 8:35pm revealed Resident #82 was transferred to a hospital. Record review of Resident #82's Crisis Safety Plan from a local behavioral hospital dated [DATE] revealed Resident #82 completed a safety plan and acknowledged it verbally on [DATE] at 5:44pm. The safety plan listed warning signs which included getting agitated, impulsivity and irritability. Internal coping strategies or things I can do to take my mind off my problems without contacting another person included listening to music, watching TV and taking a nap. Record review of Resident #82's admission Note dated [DATE] revealed Resident #82 was readmitted to the facility. Further record review of Resident #82's care plan dated [DATE] revealed it was not revised when Resident #82 was readmitted to the facility on [DATE]. In an observation and interview on [DATE] at 10:12am, Resident #82 was in her room seated in a wheelchair facing the hallway. Her belongings were packed in boxes by her nightstand. She said she used to be homeless and lived on the streets. She said when she was homeless, she stabbed herself in the stomach. She said she recently arrived from the hospital. She said she was worried that the facility was going to ask her to leave.In an interview on [DATE] at 5:00pm, LVN I stated Resident #82 had recent suicidal ideations and was sent to a behavioral hospital. He said she had some anxiety about the facility discharging her somewhere else, so he reassured her that she was allowed to stay. In an interview on [DATE] at 7:45am, LVN H said she was present when Resident #82 had suicidal ideations. She said Resident #82 had some favorite staff members and stated she (LVN R) would call her favorite staff members and let Resident #82 talk to them on the phone to reassure her that everything was okay. In an interview on [DATE] at 9:34am, ADON F stated the nursing staff gave Resident #82 special attention due to her mood. She said she noticed that when they spoke to her for a long time, it would trigger depressed mood or agitation. She said they helped her to the dining room and encourage activities to make sure she was occupied. She said she thought Resident #82's history of suicidal ideations should be care planned. She said the MDS nurses were new and they had staff from different buildings helping with resident care planning.In an interview on [DATE] at 4:35pm, DON L said she was not aware that Resident #82's discharge hospital records included a safety plan. She said it would be important for staff to know what was in her safety plan so they can help her. A policy regarding care planning was not provided by the time of exit.

Based on interview and record review, the facility failed to ensure individuals with mental health disorders were provided accurate Preadmission Screening and Resident Review (PASRR) screening for 1 of 19 residents (Resident #3) reviewed for resident assessments.The facility did not correctly identify Resident #3 as having a mental disorder on their PASRR Level 1 Screening.This failure could place residents with mental disorders at risk of not receiving specialized PASRR service which could contribute to a decline in physical, mental, psychosocial well-being, and quality of life. Findings included: Resident #3Record review of Resident #3's medical record from another nursing facility dated 3/24/26 revealed Resident #3 had a diagnosis of schizophrenia with a start date of 1/3/2020. Record review of Resident #3's admission Record generated on 6/9/26 revealed he was admitted to the facility on [DATE] with diagnoses of hemiplegia, cerebral infarction, chronic kidney disease and schizophrenia. He was [AGE] years old. Record review of Resident #3's admission MDS assessment dated [DATE] revealed he had an active diagnosis of schizophrenia. He had a BIMS score of 6, indicating he had severe cognitive impairment. Record review of Resident #3's PASRR Level 1 Screening dated 4/6/26 revealed it was completed by an MDS Coordinator from another nursing facility. The screening form indicated Resident #3 did not have a primary diagnosis of dementia (an umbrella term for a decline in mental ability-such as memory, thinking, and reasoning-severe enough to interfere with daily life) and did not have a mental illness nor an intellectual or developmental disability (lifelong, chronic conditions that typically originate before age [AGE], affecting a person's physical, intellectual, and/or emotional development). In an interview on 6/8/26 at 1:05pm, Resident #3 said he moved to the facility from another nursing home. He said he was at the facility to stay for long-term care. In an interview on 6/10/26 at 8:54am, the Regional Reimbursement Nurse stated both of the facility's MDS nurses were new to their position. She said the MDS nurse was typically responsible for the PASRR process. She said she would look for Resident #3's PASRR assessments. In an interview on 6/10/26 at 10:30am, the Regional Reimbursement Nurse said after looking at Resident #3's PASRR, she found that the screener who completed the PASRR Level I completed the form incorrectly. She said that she was responsible for monitoring the PASRR assessments in April 2026, and she did not notice it was incorrect. She said they should have completed a revision because of his diagnoses and referred him for a PASRR Level II assessment. In an interview on 6/11/26 at 4:35pm, DON L said she did not monitor the PASRR process and said she was not familiar with PASRR services and why they could be beneficial to the residents. Record review of the facility's policy regarding PASRR Level 1 Screen Policy and Procedures dated 3/6/19 read, It is the policy of (nursing home company) to obtain a PL1 screening form from the RE (referring entity) prior to admission to the (nursing facility). The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible. The Facility will review the PL1 Screening Form for completion and correctness prior to admission and submit the PL1 form per regulations.

Based on record review and interview, the facility failed to ensure a resident who is diagnosed with Dementia received the appropriate treatment and services to maintain his/her highest practicable physical, mental and psychosocial well-being for one (Resident #2) of five residents reviewed for behavioral health. The facility failed to ensure Resident #2's dementia diagnosis was addressed in her plan of care goals and interventions. This failure could place residents at risk of significant cognitive decline and a decrease in quality of life. Findings include: Record review of Resident #2's face sheet revealed a [AGE] year-old female with an admit date of 12/29/2023 and diagnosis of Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Dominant Side (stroke affecting the right hemisphere of the brain), Vascular Dementia (a decrease in blood flow to the brain, which can damage brain tissue) and Bipolar Disorder. Record review of Resident# 2's MDS assessment dated [DATE] revealed a BIMS score of 03. Record review of Resident #2's care plan dated 04/27/2026 revealed Resident #2 as at risk for wandering and elopement. There was no mention of Resident #2's diagnosis of Vascular Dementia nor any goals or interventions related to this diagnosis on the care plan. During an interview on 06/11/2026 at 10:14 AM with Resident #2, she said she had problems remembering. She said she needed reminders sometimes. She said staff did provide reminders with tasks for her. She said she required reminders about once a week. During an interview on 06/10/2026 at 12:25 PM with DON L, she said care plans were the responsibility of the MDS. She said Resident #2 does require dementia care related to her stroke. She said dementia care would include reminders and assistance to help the resident with ADLs. She said a diagnosis of Dementia should be addressed in a resident's plan of care. She stated dementia care is important because it helps the resident maintain quality of life. During an interview on 06/10/2026 at 1:30 PM with the Regional Reimbursement Nurse, she said if a resident had diagnosis of Dementia, it should be care planned. She said care plans are assessed and revised at least quarterly for all residents. She said a resident with Dementia, who does not have goals or interventions in their care plan to address it, could put them at risk of not getting proper care. She said the resident could miss out on cues and encouragement to help her with her diagnosis. She said this lack of intervention could lead to a decline for the resident. During an interview on 06/10/2026 at 3:36 PM with the Administrator, she said the importance of having dementia care was to make sure a resident receives person centered care. She said dementia care addresses behavior, cognition issues and keeping the resident safe. She said if a resident is diagnosed with Dementia, it should be documented in their care plan. She said the MDS is responsible for care plans, but the nurses are able to update and make revisions as well. She said the facility would be out of compliance if they aren't care planning services for residents who have dementia. She said by not having dementia care in a care plan, a resident could miss services that would help them to thrive and maintain their quality of life. Record review of facility Dementia policy revealed It is expected that a facility's approach to care for a resident with dementia follows a systematic care process in order to gather and analyze information necessary to provide appropriate care and services and that it is important for the facility to have systems and procedures in place to assure that interventions are described, consistently implemented, monitored, and revised as appropriate.

Based on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were properly discarded and the medication storage room was maintained in accordance with currently accepted professional principles for 1 (100 Hall) out of 2 medication storage room and 2 (300 B Hall) out of 3 medication carts reviewed for pharmacy services. The facility failed to ensure 100 Hall medication storage room did not have non-medical items. The facility failed to ensure expired medications for Resident # 28 was removed from 300 B Hall nurses' cart and MA cart. These failures could place residents at risk of receiving discontinued medication, receiving potentially harmful side effects from expired prescribed medications and drug diversion. Findings include: During observation of 100 Hall medication storage room on 06/09/2026 at 8:40 am with ADON J, one of the cabinets contained 2 packs of unopened instant noodles, 15 pieces of foam plates, 5 pieces of foam take-out boxes. Another cabinet had a bucket containing a bottle of after shave, 2 bottles of lotion, 1 deodorant, 2 bottles of shampoo, 1 Dove soap, and 3 lip balms. During an interview on 06/09/2026 at 8:50am, ADON J stated these toiletries were for residents' use but was unsure if it was for a specific resident. ADON J stated there should not be any non-medical items stored in the medication storage room. ADON J stated she was unsure why someone would keep noodles, plates, and take out boxes in the medication room. During observation of 300 B Hall Nurse's cart on 06/09/2026 at 3:03pm with LVN E and RN K revealed Resident #28's Budesonide Inhalation Solution 0.5mg/2ml issued on 12/28/2025 had no open date; During an interview on 06/09/2026 at 3:35pm, RN K stated discontinued or discharged medications should not be kept in the medication cart. RN K stated that the discontinued or discharged medications should be placed in the Discharge Medication bin which was in the 300 Hall medication storage room. RN K stated discontinued controlled drugs should be returned to DON immediately. RN K stated if discontinued medications are not removed from the cart, it may result in medication error or drug diversion. RN K stated carts should be audited daily. During an observation of 300 B Hall MA cart on 06/09/2026 at 4:10pm with MA B, Resident #28's Latanoprost Solution 0.005% issued on 03/14/2026 with instructions from pharmacy to discard medication 42 days after 1st use did not have open date. During an interview on 06/09/2026 at 4:25pm, MA B stated if a resident was in the hospital, they would keep the medications in the cart for 5 days and will check with the nurse if the resident was coming back. If the resident was not returning, the medications would be placed in the pharmacy return bin. During an interview on 06/11/26 at 10:44am, DON stated her expectation was for nurses to remove expired medications, remove medication for residents that are in hospital and remove controlled medications within 3 days of resident leaving the facility. DON stated the medication storage room should be kept locked, clean and well stocked with no food, drinks or non-medical items. DON stated nursing managers will box expired medications and have pharmacist verify, sign form and send medications for destructions. DON stated drug destructions are done monthly for controlled and non-controlled drugs. DON stated the last destruction was conducted on 06/03/2026. Record review of facility's policy titled PCU027 - Medication Storage in the Facility, P&P, v3-2025 read in part .Procedures: #13) Outdated, contaminated, or deteriorated medications. are immediately removed from stock and disposed of according to the procedures of medication destruction and reordered from pharmacy, if a current order exists. #14) Medication storage areas are kept clean, well lit and free from clutter. Record review of facility's policy titled PCU019 - Controlled Medications - Administration (revised 04/06/2026), P&P, v3-2025 read in part .Procedures: #13) Controlled medications remaining in the facility after the order has been discontinued are retained in the facility, in a securely locked area with restricted access, until destroyed by facility DON, Administrator or Consultant Pharmacist .

Based on observation, record review, and interviews, the facility failed to ensure adequate supervision to prevent accident hazards for one (Resident #53) out of five residents reviewed for quality of care. The facility failed to ensure Resident #53 was supervised while smoking and receiving oxygen therapy. This failure could place residents at increased risk of fires and burns. Findings include: A record review of Resident #53's face sheet revealed a [AGE] year-old male with an admit date of 05/15/2020 and diagnosis of COPD (a progressive, incurable lung condition that blocks airflow and makes breathing difficult), Congestive Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should), and Need for Assistance with Personal Care. Record review of Resident #53's MDS assessment dated [DATE] revealed a BIMS score of 07. Record review of Resident #53's care plan dated 03/07/2026 revealed resident as having oxygen therapy, an ADL self-care performance deficit, muscle weakness and as a smoker. Interventions included for resident to smoke in designated areas, keep all smoking materials at nursing station, monitor when smoking to assure safety and perform smoking assessment according to facility policy. Record review of Resident #53's order summary revealed an order for oxygen at 2 liters per minute via nasal cannula. Record review of the Safe Smoking Assessment for Resident #53 dated 06/09/2026 revealed there were no smoking assessments for the resident prior to this date. Resident #53 was deemed an unsafe smoker due to: - wearing oxygen- not being able to dispose of ashes or other tobacco-related residue appropriately- not being able to independently light smoking materials safely - not being able to extinguish smoking material completely in an appropriate receptacle Record review of the facility's Smoking List dated June 2026 revealed Resident #53 was not included as a smoker. Smoke break times were identified as 8:30AM, 11AM, 1:30PM, 3:30PM and 6:45PM. The designated smoking area was listed as 300 hall patio area. During an observation and interview on 06/09/26 at 12:34 PM, Resident #53 was observed outside in his power chair near the facility dumpsters. An unlit rolled white paper was in his right hand. The white paper was about an inch in length and appeared to be burned on the end. Resident #53 had a nasal cannula in his nose which was connected to his portable oxygen device. The device was attached to the back of his power chair and on. Resident #53 presented with a flat effect, was staring off into the distance, did not make eye contact and his speech was incoherent. Resident #53 advised he had been smoking outside. He said he was experiencing some sadness due to the passing of a family member. Resident #53 said he was aware he was not supposed to smoke due to his oxygen. Further observation of the area surrounding the dumpster revealed over thirty cigarette butts in various stages of decomposition. During an interview on 06/09/26 at 1:15 PM with DON L, she said Resident #53 was on the smoking list. She said he is supposed to be supervised while smoking. She said Resident #53 is aware his oxygen should be removed when smoking. She said the area near the dumpsters is not a designated smoking area. She stated the designated smoking area has been communicated to both staff and residents. She said smoking outside of the designated areas could put residents at risk of an emergency. She said Resident 53 is specifically at risk for setting something on fire or burning because he uses oxygen. She said if Resident #53 smokes with his oxygen, he could cause an explosion. During an interview on 06/09/26 at 2:30 PM with Dietary Aide N, she said she was outside, this afternoon, by the dumpsters where she observed Resident #53. She said Resident #53 appeared to be asleep. She said she was outside to take a break. She said she was not aware of anyone smoking in that area. She advised she does smoke, but stated she walks to the corner to do so. She said she hasn't noticed any cigarette butts on the ground near the area. She said staff are designated to smoke in the same place as the residents. She said she doesn't know of anyone smoking in that area and denied seeing Resident #53 smoking. She said she has never seen Resident #53 outside in that area and is not sure if he smokes. She said she doesn't work with residents since she is in the kitchen. She said the importance of having designated areas to smoke is to keep people safe. She said it would not be safe to smoke around oxygen. During an interview on 06/09/26 at 2:57 PM with CNA O, she said she was recently outside on break where she observed Resident #53. She said she stood there all the time for breaks. She said when she smokes, she goes down the street or smokes in the designated area. She said she has seen other residents and staff outside in that area. She said she has observed other staff outside smoking in that area and had noticed cigarette butts over there on the ground. She said this was her first time seeing Resident #53 there. She said he is usually outside on the patio. She said she didn't say anything to Resident #53 because he looked like he was asleep. She said she is not sure if Resident #53 is a smoker or not. She said it is not safe for Resident #53 to smoke because he has oxygen and it could blow up or bust. She said designated smoking areas provide safety and supervision to the residents. She said having designated area ensures no one who is not allowed to smoke can't be outside smoking. During an interview on 06/10/26 at 3:17 PM with the Administrator, she said she was not aware of any residents or staff smoking outside near the dumpsters. She said she did not go near the dumpsters and therefore, has not observed any cigarette butts there. She said the importance of having designated smoking areas is so that residents are supervised and remain safe while smoking. She said residents smoking while on oxygen is dangerous because it could cause an explosion. She said Resident #53 is not considered a safe smoker. She said she has not observed Resident #53 smoking. During an interview on 06/11/26 at 9:53 with Resident #53, he said he was smoking marijuana. He said he found the marijuana cigarette outside in the parking lot. He said he was looking down at the ground, saw it, and picked it up. He said he already had a lighter. He advised that he took two puffs of the marijuana. He said he did not normally smoke. He said he has had a lot of stuff going on with his health and a death in the family; and his mind hasn't been right. He said he knows he is not supposed to smoke because he is on oxygen and could blow up. He said he has never smoked at the facility. He said this was his first time smoking at the facility. He said he went to that area of the parking lot for some shade. He advised he has seen other people smoking in that area. Record review of the facility's Smoking policy revealed the facility is responsible for smoking policies which included: - Lighters are not permitted to be kept in residents' rooms. - A safe smoking assessment will be done regularly for each resident who smokes. - Smoking is only allowed in designated smoking areas. - Smoking is prohibited in any area where oxygen is used. - Residents and employees are prohibited from smoking in any part of the facility or grounds except in designated smoking areas. Record review of the facility's High Pressure Oxygen Cylinder policy dated 06/01/2006 stated, Fire hazard is increased in the presence of oxygen. No smoking or open flame within five feet of oxygen.

Based on interviews and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents ( Resident #1) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #1 from falling to the floor and injuring himself during patient care on 01/09/26 and resulted in a laceration to his upper lip which required stitches. This deficiency could expose residents to harm and injury, due to not being adequately monitored. Findings include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. His diagnoses included Immobility Syndrome (Paraplegic), Muscle weakness (generalized), cognitive communication deficit, Hyperlipidemia, Unspecified, Contracture of muscle, unspecified site, Dysphagia, Oral Phase, and Need for assistance with personal care. Review of Resident #1's MDS assessment dated [DATE], section C revealed no BIMS score. Section G regarding the resident's Activities of Daily Living (ADL) Assistance revealed the resident needed supervision and two persons assisting with bed mobility, transferring, and toilet use. It also revealed the resident required two-person assistance with dressing and personal hygiene. Record review of Resident #1's care plan dated 11/12/2025 revealed Resident #1 was care planned for falls. ADL Self-Care Performance Deficit: requiring two-person assist with all ADL except for eating. Record review of CMA-A's signed statement dated 01/09/26 revealed she was providing patient care for Resident #1. The statement read in part, .Resident #1 became agitated. So, I stopped to calm him down, and after he calmed down. I started providing patient care again; however, Resident#1 became agitated again, and as I was wiping him, he fell to the floor, landing face down and on his left side. I observed blood, and I called for help. Record review of Resident #1's hospital record dated 01/09/26 revealed that Resident #1 was diagnosed with a fall, which resulted in a laceration to his upper lip. Resident #1 received stitches to treat his upper lip. Record review of Resident #1's progress note dated 01/09/26 revealed that he returned to the facility at 7:48 p.m. with one stitch to his upper lip due to sustaining a laceration from a fall. Record review of the facility's Provider Investigation Report dated 01/20/2026 and signed by the Administrator revealed, . CMA (CMA A) provided care to Resident (Resident #1) alone when his care plan called for two-person assist. He rolled out of bed on to the floor . Resident (Resident #1) sustained a laceration to his lip during the fall . Order received and carried out to send Resident (Resident #1) to (a local acute care hospital) ER for evaluation and treatment . All staff were trained (In-services on transfers, mechanical lift transfers, bed mobility, and repositioning with return demonstration) and CMA (CMA A) was terminated as it was found she failed to care for him without getting the assistance of a second staff member. Ad-hoc QAPI was held regarding fall . An audit was done on January 9-10 2026 to ensure residents care plans accurately reflected each resident's assessment needs . In an interview on 01/13/26 at 9:45 a.m., the Administrator stated CMA A was terminated because on 01/09/2026, CMA-A failed to provide appropriate patient care on Resident #1. The Administrator said CMA A should have used a two- person assist for care and because of CMA-A's failure to follow Resident #1's care plan for two-person assist, he fell out of his bed and sustained an injury to his top lip. Resident #1 was taken to the hospital, and his injury required stitches. In an interview with the ADON on 01/13/26, at 9:55 a.m., she stated that CMA A should have checked the Kardex before providing care for Resident #1. She stated the Kardex would have informed her that a two-staff member assist was the safest way to provide care for Resident#1 to prevent injury. An unsuccessful attempt to interview Resident #1 was made on 01/13/2026 at 10:35 a.m. However, observation reflected that Resident #1 did have stitches in his upper lip. In an interview with CNA-A, 10:40 a.m., CNA-B, 10:43 a.m., CMA-B,10:46 a.m., and LVN-A10:50 a.m. on 01/13/26, they stated as a result of Resident #1's incident, they were in-serviced last week on where to look to know if a resident is a two-person assist and if the resident is a Hoyer lift. An unsuccessful attempt was made to contact CMA A on 01/13/2026, at 11:26 a.m. and at 9:30 a.m. on 01/14/2026. In an interview with the MDS Nurse on 1/13/26 at 1:00 p.m., she stated that Resident #1 was a two-person assist with all ADL except eating. In an interview with the Administrator on 01/13/26 at 3:45 p.m., she stated that during her investigation, CMA A told the DON that she did not understand that she was supposed to use two people to assist. The Administrator stated that CMA A was recently in-serviced at the facility on what residents required the Hoyer lift, and where to look in the Kardex to know if a resident is a two-person assist. The Administrator stated that Resident #1 had to be taken to the hospital due to his fall from his bed during patient care with CMA A. The administrator stated that Resident #1 required stitches to his upper lip. Record review of facility in-services revealed all staff were educated on:*Hoyer lift, gait belt, and Kardex check before providing patient care on 01/09/2026.*Transfers and Safe patient handling on 01/09/26.*Abuse and Neglect on 01/09/2026*Abuse/Neglect on 01/09/2026. Record review of facility Safe Handling Policy(not dated) revealed, . The facility has a program to promote and assure safe patient handling for both the resident and the employee. Nurses will identify residents in need of transfer, repositing or movement assistance.Nurses will assess the risks associated with lifting, transferring, repositioning, or movement assistance Nurses will be educated in the identification, assessment, and control of risks of injury to residents and nurses during. Resident will be evaluated on admission and as needed for alternative means of lifting. Transferring, repositing and other movements to minimize risk of injury.patient handling. Nurses will be educated regarding correct safe handling procedures; to report concerns or the inability to perform resident handling or movement that the nurse believes in good faith will expose a resident or nurse to unacceptable risk or injury. 6. Facility staff will report to the supervisor the inability to complete resident lifting, transfer, or repositioning if they feel it will either endanger the resident or cause injury to staff. 7. Nursing will request therapy disciplines to evaluate the resident ability to assist, and the amount of assistance needed with lifting, repositioning, transferring or mobility.

Based on interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (CR #1's) reviewed for adequate supervision. -The facility failed to provide adequate supervision to prevent CR #1 from eloping from the facility at an unknown time on 9/21/25. This deficiency exposed residents living in the facility to potential harm, injury, or death due to not being adequately monitored. An Immediate Jeopardy (IJ) was identified on 11/18/25. The IJ template was provided to the facility on [DATE] at 4:41 pm. While the IJ was removed on 11/19/25, the facility remained out of compliance at a scope of with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective system. Findings included: Record review of CR#1's face sheet dated 11/18/25 revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. CR #1 discharged on 10/07/25. His diagnosis of Parkinson's Disease with Dyskinesia (experiencing involuntary, uncontrolled movements), Cognitive Communication, Dementia with Agitation (restlessness, pacing, verbal aggression like yelling, and physical aggression such as kicking or biting). Traumatic brain injury (resulting from an external force), which may impact cognition, behavior, or functional status. Record review of CR #1's admission MDS assessment, dated 9/11/25, revealed the BIMS score was six out of fifteen, indicating he had significant cognitive impairment. Further review of MDS revealed CR #1 needs moderate assistance with supervision with one staff assistance. Record review of CR #1's care plan dated 06/16/22 revealed CR #1 has a short attention span wandering in and out of activities. Further review of the care plan revealed CR #1 was an elopement risk/wander dated 11/08/23. care plan reviewed and had interventions for risk of elopement due to wandering that included a wander guard in place that was to monitor per shift and alert staff of CR #1 attempts to leave the facility unattended. Monitor location per shift. Observing the wandering behavior and attempted the diversional interventions in behavior log. Revision dated 01/31/24. During an interview on 11/17/25 at 10:30 am, the video was requested by the ADM but the video for the incident on 9/21/25 was not provided. Record review of email on 11/17/25 at 12:31 pm. surveyor requested a video of the incident from the Regional Corporate Compliance Nurse. During interview on 11/17/15 at 2:06 p.m. Dietary-aide A, said he observed CR #1 enter the lobby, sit down, and then stand and begin pacing back and forth. He said when he left the lobby, CR #1 remained in the lobby area pacing up and down. During an interview on 11/17/25 at 2:42 pm. ADON said that CR #1 walked out with church members, but she was not present and did not know who could have opened the door. She said someone would have to unlock the door for CR #1 to be able to leave. She said whoever unlocked the door had a visual of whoever was leaving the facility. She said she did not know why the staff had not identified CR #1 before he walked out the front door. She said CR #1 was at risk and could have experienced death, been hit by a car, or been picked up by someone. During a telephone interview on 11/17/25 at 3:14 pm. RN B said LVN C came from station 3 and told her CR #1 was on the street. She said she did not know how CR #1 left the facility. She said CR #1 could have had a fall or hit by a car. During an interview on 11/17/25 at 3:33 p.m., the Social Worker said he was the manager on the day of the incident. Staff told SW that CR#1 was out of the facility. SW said he was close to the facility and was going to drive to CR #1 location. SW said the police officer was walking with CR #1. SW said he identified himself, and CR #1 recognized him and said he was ready to go home. SW said CR #1 immediately got into his car. SW said none of the staff knew which door CR #1 went out of. He said CR #1 did not have a wander guard on. He said the risk to CR #1 getting out of the facility was CR #1 could become lost and could have gotten hurt. During an interview on 11/17/25 at 4:31 pm. Regional Corporate Compliance Nurse, said CR#1 had gone out with the church group because there was a church group that morning. He said a staff member should have let the church group out and had a visual of who they were letting out of the facility. He could not give a time of how long CR#1 was out of the facility. He said they should have observed CR#1 was among the church group. He said CR#1 could have been injured, had a fall, been hit by a car, and/ or received other negative outcomes. During an interview on 11/18/25 at 8:56 am. CMA D said she saw CR #1 while she was in an Uber and called CR #1 by name. She said she exited the vehicle and called the facility and spoke with LVN C to inform her that CR #1 was no longer in the facility. She said she got out of the car and repeatedly called CR #1 by name, but CR #1 became aggressive. She stated the risk to CR #1 was significant, as CR #1 could have been hit by a car due to how fast CR #1 was moving. She said CR#1 was not paying attention to his surroundings, and she feared for his safety. She said that if CR #1 had gone one more block, CR #1 would have entered the freeway, but she was able to stop CR #1. During a telephone interview on 11/18/25 at 8:56 am. with LVN C, said she had no idea how CR #1 eloped from the building because she was helping on the floor with other residents. She said CR #1 could have been killed. LVN C said CR #1 has no sense of direction. She said CR #1 was trying to escape by crossing the street while looking backwards instead of at the cars in front of him. Telephone interview on 11/18/2025 at 10:22 am. with the facility's previous administrator stated she did not have time to answer any questions related to the elopement incident. During an interview on 11/18/2025 at 1:43 pm, the Regional Corporate Compliance Nurse said he requested access from IT for the video. Record review of the facility's policy on Elopement Prevention from Nursing Policy and Procedure Manual documented MM TIW WA 03-1.0 read in part. policy statement Every effort will be made to prevent elopement episodes while maintaining the least restrictive environment for residents who are at risk for elopement . 7. If a resident is discovered to be missing, a search shall begin immediately. Environmental Modification 6. Use door alarms or monitoring devices to notify staff when residents try to leave the facility. Physical Plant 1. All facility exits that residents have access to will have a device in place to alert staff of possible elopement attempts. Example of these devices: Wanderguard System (locking or alarming) Placement of the residents' device to alarm the system will be verified each shift and documented on a treatment or other flow record. Function of the resident's device will be verified at least daily and documented on a treatment of other flow record. Function of the alarm system will be verified each week and documented in a maintenance log. 3. All exit devices will be verified weekly and a log maintained. Record review of the facility's policy on Elopement Response from Nursing Policy and Procedure Manual documented MM TIW WA 03-1.0 read in part. policy statement Nursing personnel must report and investigate all reports of missing residents. When an elopement has occurred or is suspected, our elopement response plan will be immediately implemented. Policy Interpretation and Implementation 1. It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the charge nurse as soon as practical. The Regional Corporate Compliance Nurse was notified of Immediate Jeopardy (IJ) on 11/18/2025 at 4:41 p.m., due to the above failures. The Regional Corporate Compliance Nurse was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The Plan of Removal was submitted by the facility and accepted on 11/19/2025 at 8:11 am.: Facility Immediate Actions: Resident CR#1 transferred to a facility with a secured unit on 10/7/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the Elopement Prevention policy on 11/18/25. Regional Compliance Nurse educated DON, ADON, and Interim Administrator regarding the Elopement Response policy, including referring to the Elopement Risk Binders located at each nurses' station on 11/18/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the operation of exit doors on 11/18/25. Regional Compliance Nurse educated the DON, ADON, and Interim Administrator regarding the process change for residents signing out on 11/18/25. 100% audit of facility residents started and completed on 11/18/25 by DON, ADON, and Regional Compliance Nurse to identify residents at risk for elopement. Findings from that audit revealed four (4) residents with a score of 10 or greater. These residents' face sheet and pictures were added to the Elopement Risk binder that is kept at each nurse's station and at the front desk for all staff to be able to identify the facility residents at risk for elopement. Care plans were reviewed and updated for the four residents identified as at risk for elopement. 100% facility audit completed by Maintenance Director on 11/18/25 of facility entry/exit doors. The Maintenance Director identified ten (10) entry/exit doors. All 10 doors locked and alarmed, and proper function of door was tested and verified on 11/18/25 by the Maintenance Director. Signage was posted at the front door and Station 1 door on 11/18/25 to notify visitors not to open the door or allow anyone else out the door they do not know, including residents. Residents and their responsible parties were notified by Department Managers on 11/18/25 and were educated on resident sign-out procedures, including the location of the sign-out book and elopement prevention. Facility Plan to ensure compliance: 1.Residents identified as having a score of ten (10) or higher on the Elopement Risk Assessment in internal health record, the facility's electronic health record, will be added to the Elopement Risk Binder located at each nurse's station and at the front desk. 2. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the Elopement Response policy starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 3. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the Elopement Prevention policy starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 are not work until in-service completed. 4. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the operation of exit doors starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 5. DON/Designee, including department heads, will in-service facility staff by phone and/or in person regarding the resident sign-out process starting on 11/18/25. Facility staff, including PRN staff, not in-serviced by 11/19/25 will not work until in-service completed. 6. The Medical Director was notified by the Administrator on 11/18/25 at 4:50pm by the Regional Compliance Nurse regarding the immediate jeopardy citation. 7. An Ad-hoc meeting held on 11/18/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan for removal. Monitoring Plan of Removal included the following: Record review of the training provided by Regional Corporate Nurse for the ADON, DON, Interim Administrator revealed staff were educated on the elopement policy, elopement binder, operation of the exit doors and how residents are to sign out of the facility. Record review of the facility audits of resident's assessments of elopement revealed 100 percent audit completed. Record review of the facility training provided on 11/18/2025 read in part. Topic: Exit Doors. Staff in-serviced and verified 11/20/2025 all exit doors have a 15 second delay-alarm will sound, and the door will open . Staff must respond to all alarms. Identify if a resident has exited, staff must stay with the residents and call for additional assistance. Record review of the facility training provided on 11/18/2025 read in part . Topic: Elopement Response. Staff in-serviced and verified 11/20/2025 all staff must notify the charge nurse as soon as possible of a resident missing or attempting to leave. If a resident is attempting to leave, try to redirect them. If a resident is suspected of being missing, the charge nurse will attempt to find out if a resident has signed out on a pass; it not on a pass, a search of the building and the premises will be initiated. Charge nurse will notify the Administrator and the DON, primary care provider, and the responsible party. The facility has an elopement risk binder at each nurse's station and at the front desk. This information can be used to assist search teams when looking for a resident. Record review of the facility training provided on 11/18/2025 read in part . Topic: Elopement Prevention. Staff in-serviced and verified 11/20/2025 residents are assessed by nursing to identify the risk for elopement . Wandering can indicate an unmet need. Interventions to redirect wandering include Toileting; Offering Food/Drink; Reduce Physical Discomfort (pain, toileting etc.). Residents can go into courtyards. If additional staff are needed to redirect residents, stay with the residents, stay with the resident, and call for help (charge nurse, Adon, Don, Administrator). Record review of the facility training provided on 11/19/2025 read in part. Topic: Resident sign out. Staff in-serviced and verified on 11/20/2025; the sign-out book will be located at the reception desk if present. When the receptionist leaves for the day, the sign-out book will be moved to Station 1 . All residents leaving the building are required to sign out. Record review of the facility training provided on 11/19/2025 read in part. Topic: Exit Doors. Staff in-serviced and verified on 11/20/2025 all exit doors have a 15 second delay-alarm will sound, and the door will open . Staff must respond to all alarms. Identify if a resident has exited, staff must stay with the residents and call for additional assistance. Record review of the facility training provided on 11/19/2025 read in part . Topic: Elopement Response. Staff in-serviced and verified 11/20/2025 all staff must notify the charge nurse as soon as possible of a resident missing or attempting to leave. If a resident is attempting to leave, try to redirect them. If a resident is suspected of being missing, the charge nurse will attempt to find out if a resident has signed out on a pass; it not on a pass, a search of the building and the premises will be initiated. The charge nurse will notify the Administrator, the DON, the primary care provider, and the responsible party. The facility has an elopement risk binder at each nurse's station and at the front desk. This information can be used to assist search teams when looking for a resident. Record review of the facility training provided on 11/19/2025 read in part . Topic: Elopement Prevention. Staff in-serviced and verified 11/20/2025 residents are assessed by nursing to identify the risk for elopement . Wandering can indicate an unmet need. Interventions to redirect wandering include Toileting; Offering Food/Drink; Reduce Physical Discomfort (pain, toileting etc.). Residents can go into courtyards. If additional staff are needed to redirect residents, stay with the residents, stay with the resident, and call for help (Charge Nurse, ADON, DON, Administrator). Record review of Monitoring Plan of Removal revealed signatures of meeting, which included Interim Administrator, DON, ADON, Medical Director, Social Services, Dietary, Activity Director, Regional Corporate Compliance Nurse, an unknown other: An Ad-hoc meeting held on 11/18/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan for removal. During an interview on 11/19/2025 with Interim ADM, DON, Traveling Corporate DON, ADON, SW, Maintenance Supervisor revealed staff in-person and or by telephone were in-serviced. Regional Corporate Compliance Nurse said if the employee or prn was not in serviced that staff employee cannot work their shift until all in-services were completed. During an interview on 11/19/2025 between 12:50 pm and 4:00pm with ADON, RN's ,B, E; Certified Occupational Therapy Assistant, 4-CMA's, D,F,G,H; 18-CNA's, I,J,K,L,M,N,O,P,Q,R,S,T,U,V,W,X,Y,Z; 2-Dietary Staff's, A, AA; 2-Facility Marketing Admission's, BB, CC; 1-Facility Director of Nursing, Laundry staff, LVN Charge Nurse's, DD, EE, FF, GG, HH, Social Worker indicated that employees had received training on elopement prevention and the steps to follow when a resident attempts to leave the building. Staff consistently reported that all exterior doors are equipped with a 15-second delayed-egress system that triggers an alarm when engaged. Staff stated they are expected to investigate all alarms immediately. Staff described their responsibilities when a resident approaches or exits through a monitored door. They stated they are to remain with the resident, attempt redirection when appropriate, and contact the charge nurse for assistance. Staff explained that if a resident cannot be located, nursing leadership initiates a search and determines whether the resident had signed out or otherwise been approved to leave the facility. Staff reported that the administrative staff, the DON/ADON, the residents' provider, and the responsible party are notified according to facility protocol. Staff also noted the presence of an Elopement Risk Binder at each nurse's station and the front desk. They stated this resource contains relevant information to support staff during search efforts. The staff in-services revealed interventions such as toileting, offering fluids or snacks, and addressing comfort to redirect residents. Staff stated if additional help is needed, they contact the nurse charge or nursing administration. The information provided was consistent with staff and aligned with the facility's in-service training conducted November 18, 2025, and November 19, 2025. The Regional Corporate Compliance Nurse, DON, Interim Administrator, Traveling DON, ADON were informed the immediate jeopardy was removed. While the IJ was removed on 11/19/25 at 4:33 pm. The facility remained out of compliance with a severity of no actual harm with potential for more than minimal harm that was not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective system.

Based on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 13 residents (Resident#2) reviewed for resident rights. 1. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 2. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 3. The facility failed to notify Resident #2's Physician when Resident # 2 had not received all ordered treatments for all of her 14 wounds from 09/30/2025 through 10/02/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 4. The facility failed to notify Resident #2's Physician when the orders given on 10/02/2025 for wound care had not been entered into Resident #2's electronic medical records or implemented from 10/02/2025 through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 5. The facility failed to notify Resident #2's Physician when Resident #2 had only as needed, over the counter regular strength Tylenol ordered for pain medications, had not received any pain medication prior to any of the wound care treatments, or had not had pain assessments prior to wound treatments for her 14 wounds. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. An Immediate Jeopardy (IJ) was identified on 10/11/2025. The IJ template was provided to the facility on [DATE] at 12:02 PM. While the IJ was removed on 10/19/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk of delays in treatment, worsening of condition, hospitalization, and death. Findings include: Record review of Resident#2's facesheet dated 10/09/2025, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE] with a principal diagnosis of cerebral infarction, unspecified (stroke), admitting diagnosis of sepsis due to Escherichia Coli (E.Coli a bacteria) and serve sepsis with septic shock (a life-threatening condition that occurs when an infection leads to dangerously low blood pressure and organ failure, and secondary diagnosis of End Stage Renal Disease(ESRD the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) pressure ulcer of sacral region, unstable, and UTI, site not specified. Secondary diagnosis dated 10/03/2025 for pressure ulcers of right buttock stage 4, left buttock stage 4,right ankle unstageable, left ankle unstageable, left heel unstageable, and other site unstageable. Secondary diagnosis dated 10/03/2025 for non-pressure chronic ulcer of right heel and midfoot, right foot, and left foot with fat layer exposed. Record review of Resident#2's admission assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making in Section C. In Section I for active diagnosis, she was triggered for ERSD, Pneumonia, Septicemia, and UTI. In Section M for skin, she was triggered to have 2 stage 4 pressure ulcers, 6 unstageable pressure ulcers, and 5 venous and arterial ulcers present upon admission. In section M she was triggered to have infection of the foot (e.g., cellulitis, purulent drainage.) In Section N for Medications, she was triggered to have antibiotics. In Section O for Special Treatments, Procedures, and Programs, she triggered to have IV medication and hemodialysis. Record review of Resident#2's comprehensive care dated 10/06/2025 reflected:Focus: Resident#2 needs hemodialysis MWF(Monday, Wednesday, and Friday) r/t(related to) renal failure.Goal: The resident will have immediate intervention should any s/sx(sign and symptoms) of complications from dialysis occur through the review date. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (MWF). Monitor labs and report to doctor as needed. Monitor/document report to MD (Doctor of medicine) s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Focus: Resident#2 has pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, Diabetes Mellitus (DM), incontinence. Present on admission: Two stage 4, Six unstageable, Five Venous/arterial ulcers, One diabetic foot ulcer. Goal: Resident#2's Pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Focus: Resident #2 is on Antibiotic Therapy r/t sepsis r/t wounds, UTI, and aspiration PNA(Pneumonia).Goal: Resident#2 will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.Intervention: Administer medication as ordered. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush, colitis, and vaginitis. Any antibiotic may cause diarrhea, nausea, vomiting, anorexia, and hypersensitivity/allergic reactions. Monitor q-shift (each shift) for adverse reaction. Observe for possible side effects every shift. Report pertinent lab results to MD. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed no care plan for pain Record review of Resident#2's hospital clinical record dated 09/25/2025 reflected diagnosis of sepsis with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pansensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident#2's hospital clinical discharge record dated 09/29/2025 reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN(solution) 100 ml (Milliliter) with piperacillin-tazobactam (Zosyn)4.5 (4-0.5) g(gram) SOLR(Solution Reconstituted) 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty(quantity): 100 GM(gram), refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident#2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident#2 discharged to treat the wounds. Record review of Resident #2's out of state hospital records, dated 09/29/2025, revealed she had the following as needed (PRN) orders for pain:Acetaminophen 650 mg tablet Q 6 hours PRN mild pain.Acetaminophen 650 mg tablet Q 6 hours PRN pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM.Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours prn for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Record review of Resident #2's facility Order Recap, dated September 2025, revealed an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. The order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's MAR, dated September 1, 2025 through September 30, 2025 revealed Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident#2's facility phone medication order date 09/30/2025 at 7:15pm for piperacillin sod-tazobactam ((piperacillin sodium-tazobactam sodium) So intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident#2's MAR for the month of September 2025 no Zosyn administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's initial skin assessment dated [DATE] at 9:22pm by LVN A, read in part, .Resident #1 had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI(Deep Tissue Injury) to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of the Resident#'2 physician order summary report reflected the following orders to treat a DTI to right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of Resident #2's MAR for the month of October 2025 reflected Zosyn administered to Resident #2 on 10/04/2025 at 8:00 PM for the initial dose. Record review of the Resident#'2 physician order summary report reflected the a wound consult was not entered at resident#2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident #2's initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 2; Unstageable (Due to necrosis [cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function]) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of physician order summary for October 2025 reflected that the orders provided initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A were not entered until 10/04/2025. Records Record review of Resident#2's progress note dated 10/03/2025 at 6:27am and completed by RN A reflected that NP A was notified of change, but there was no information detailing what the change was or orders to address the change. Records Record review of Resident#2's SBAR dated 10/03/2025 at 6:05am and completed by RN A did not reflect specific information of notifying NP A her missed hemodialysis session or orders from NP A to address the missed hemodialysis session. Record review of Resident #2's MAR, dated October 1, 2025, through October 31, 2025, revealed the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Record reviews of Resident #2's electronic medical record revealed no PAINAD assessments for Resident #2. In an observation on 10/09/2025 at 10:57 AM revealed ADON A performed Resident#2's wound care with assistance from CNA A. ADON A said at the start of the treatment Resident #2 was medicated for pain about 30-40 minutes prior. Resident #2 was observed to tolerate the wound care treatment without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed as if she were in pain. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said that the her clinical impression was that some of Resident#2's wounds were infected at the time of admission, and it was apparent that she had recent debridement of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36pm with the Medical Director, she said that she was the primary physician for Resident#2. She said that staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said that she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said that Resident#2 IV antibiotics should be arranged prior to a residents admission, and if it was not available orders could be arranged to switch to an oral antibiotic until it was available. She said that a wound consult should made upon admission, and the orders given after the wound consult should be entered and carried out. In a follow up interview on 10/09/2025 at 5:14pm with ADON A, she said that that the admitting nurse completes an initial skin assessment at the time of admission. She said that the treatment nurse should complete a second skin assessment on new admission with wounds identified within 24 hours of admissions. She said that the treatment nurse should review the facility clinical records and hospital clinical records. She said that the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said that there should be a clinical review of all new admissions the next business day with the Administrator and clinical department heads present. She said that she worked as treatment nurse on 09/30/2025 and 10/01/2025. She said that Resident#2 admitted on [DATE] with wounds, and orders for Zosyn. She could not recall if the order for Zosyn was to treat a wound infection or UTI. She said that she did not complete the second skin assessment for Resident#2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she is not able to finish by the end of her shift. She said that ADON B would have been responsible for complete Resident#2's wound care treatment after admission. She said that she did not recall if she attended the clinical admitting on 10/01/2025. She said that LVN A was responsible for ensuring that medications and treatments were reconciled at the time of admission and entering the orders. She said that Resdient#2 did not have orders treat all her wounds or Zosyn at the time of admission. She said that a clinical review of Resident#2's admission should have caught the error. She said that the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30pm with ADON B, she said that she worked on 09/30/2025 and 10/01/2025 from 10:00pm -6:00am. She said that she did not assist with the admission of Resident#2, and the admission was completed by LVN A. She said that LVN A did tell her that Resident #2 admitted with wounds with treatment orders from the hospital. She said that she did complete Resident#2's wound care on 10/01/2025. She said that no one communicated to her to complete a skin assessment as the treatment nurse for Resident#2. She said that she is not the treatment nurse for the facility, but she does help with wound care. She said that she started as an ADON on 10/09/2025, prior to she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In an interview on 10/09/2025 with the DON, she said that she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted on [DATE]. She said that there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator present. She said that the clinical review should be to review the admission process for accuracy and correcting errors made. She said that she had not completed an assessment of Resident#2 since the time of admission. She said that she was not aware of Resident#2 to have not received antibiotics from the time of admission. She said that she was not aware that Resident#2 did not have skin assessment completed by a treatment nurse after admission. She said that it was the responsible of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said that she was not aware that resident did not have orders to treat all wounds or wound consult upon admission. She said that she was not aware that Resident#2 had missed a dialysis treatment after admission. She said that she could not recall if there was a clinical review of Resident#2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41pm with the Administrator, she said that she does not always stay for daily clinical meetings with the clinical department heads after the daily stand up meeting. She said that she did not believe that she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said that the DON is the clinical oversight for the facility. She said that the DON should review all new admissions, re-admission, change in conditions, and the 24 hour report for accuracy. She said that the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 9:32am at the beside of Resident#2 who was non-verbal or interviewable . In an interview on 10/10/2025 at 9:38am with in-house Hemodialysis Nurse, she said that on 10/03/2025 Resident#2 could not receive hemodialysis due to a change in condition, elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resdient#2, and she communicated with Resident #2's nurse(name unknown) about the the order for Metoprolol. She said that Resident#2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said that when a resident does not receive hemodialysis as scheduled, they are usually sent to the hospital to receive hemodialysis. She said that she later found out that Resdient#2 was not sent to the hospital. In a phone interview on 10/10/2025 at 10:05 am with RN A who worked the 10:00pm-6:00am, said she notified NP A that Resident #2 had not received her hemodialysis on that 10/03/2025, because her hear rate was too high. RN A said NP A gave an order to re-evaluate Resident #2's vital signs and heart rate within an hour and call him back. She said that Resident#2's heart rate remain high, she sent a text message to notify NP A, NP A never responded to her text, and she did not receive any orders to administer medications to Resident #2. She said that she never administered any medication to Resident #2 because it was the end of her shift and that the Hemodialysis Nurse was the one who gave Resident #2 Metoprolol. RN A did not reply when asked why she documented in Resident #2's SBAR dated 10/03/2025 that she had spoken with NP A and received orders for medication Metoprolol. RN A said that this all happened at the end of her 10pm-6am shift, and she gave report to the on-coming nurse(LVN D) about Resident #2's elevated heart rate and missed dialysis. RN A said she could not recall if she specifically asked NP A about any orders for Resident #2 to receive dialysis and said she did tell NP A that Resident #2 had missed or was unable to get dialysis that day. RN A said she either told ADON A or LVN D about the missed dialysis and elevated HR, she was unsure if she did tell ADON A or LVN D, and unsure if she documented the information on the 24 hour report In an interview on 10/10/2025 at 11:10am with NP B, he said that he is the nurse practitioner for the facilities Medical Director. He said that Resident#2 admitted on [DATE] while he was off, NP B covered for him, and NP B saw Resident#2 on 10/01/2025. He said that Resident#2 admitted with wounds, and she was being treated with IV antibiotics, Zosyn, for UTI and Wound culture for E.Coli while in hospital, and the Zosyn was to continue for 2 weeks after discharge. He said that he was asked to see resident number today on 10/10/2025 by the Medical Director and that was his first time meeting Resident#2. He was unsure when the Resident#2 received the first dosage of the Zosyn, but it should start no later than the next day after admission. He said that his expectation would be that all medications and treatments start no later than the next day after the order is given. He said that the risk is that conditions or infections could worsen. He said that it was his expectation that a physician or nurse practitioner be notified when medications were not available to seek additional orders to treat. He said that if he had been notified that Resident#2's Zosyn was not available he would have send her back to the hospital, as there would ve no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen. He said that he was not aware of Resident#2 to missed dialysis for any day or reason, but the physician should be notified if there was a change in condition that would affect a resident not receiving dialysis or any care. He said that if a resident missed dialysis, they would be sent to the hospital to get the treatment. He said that it was important for staff to notify a physician of wounds upon admission and once identified. He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital. In an interview on 10/10/2025 at 11:10am with the DON A, she said that RN A completed the SBAR on 10/03/2025 for Resident#2, she reviewed the SBAR (Situation, Background, Assessment, and Recommendation), and there was nothing documented about a change in the residents conditions that prevented Resident#2 from receiving dialysis, that notification was made to a physician or nurse practitioner, or what a physician or nurse practitioner wanted to do about the missed dialysis. In an interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident#2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident#2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he would have decided on a different treatment plan. He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor. He said that he would not speak on risks to residents, or if Resident#2 should have been sent to the hospital. He said that his expectation is that staff make enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missed, and when there is a change in condition. In an interview and observation on 10/10/2025 4:59pm at the beside of Resident#2 of ADON B to perform Resident#2's wound care treatment with MA E, and DON present. Both ADON B and MA E said that Resident#2 were medicated prior to treatment for pain. Observation of ADON B to cut away the bandage to Resident#2 left foot that was stuck to the wound without using a saline spray to loosen the bandage. ADON B was observed not to look a Resident#2 to non verbal signs of pain. Resident#2 was observed to show facial grimace. ADON B was asked if she would use a saline spray to loosen the bandage in which she did, and continued to pull the bandage from the wound. Resident#2 was observed with tears in both eyes. ADON B was asked what medication was used to manage the pain of Resident#2, to which she replied Extra Strength Tylenol. ADON B was asked to stop the treatment. DON A told ADON B to contact the physician to see if Resident #2 could have something stronger for pain. In an interview on 10/10/25 at 5:26pm with the Administrator A, she was told of the observation made of Resident#2's wound care and concern for pain management. Administrator A said the concerns were clinical concerns and she would have to speak with the DON Ato gather more information on the sit

Based on observation, interview and record review the facility failed to ensure the resident had the right to be free from neglect for 2 of 13 residents (CR#1 and Resident #2) reviewed for neglect.1. The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE].2. The facility failed to notify Resident #2's Physician when they failed to administer IV antibiotic, Zosyn, as ordered from admission on [DATE] through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.3. The facility failed to notify Resident #2's Physician when she was unable to receive Hemodialysis treatment as ordered on 10/03/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.4. The facility failed to notify Resident #2's Physician when Resident # 2 had not received all ordered treatments for all of her 14 wounds from 09/30/2025 through 10/02/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities.5. The facility failed to notify Resident #2's Physician when the orders given on 10/02/2025 for wound care had not been entered into Resident #2's electronic medical records or implemented from 10/02/2025 through 10/04/2025. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. 6. The facility failed to notify Resident #2's Physician when Resident #2 had only as needed, over the counter regular strength Tylenol ordered for pain medications, had not received any pain medication prior to any of the wound care treatments, or had not had pain assessments prior to wound treatments for her 14 wounds. Resident#2 was transferred to a local hospital on [DATE] with elevated WBC, diagnosed with sepsis, treated with IV antibiotics, and had a bilateral AKA due to lack of blood flow and necrotic tissue to both extremities. An Immediate Jeopardy (IJ) was identified on 10/13/2025. The IJ template was provided to the facility on [DATE] at 12:13 PM. While the IJ was removed on 10/20/2025, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures could place residents at risk for delayed treatment, worsening of condition, increased pain, hospitalization, and death Findings include:1. Record review of CR#1's face sheet, dated 09/30/2025, reflected a [AGE] year-old male, who admitted to the facility on [DATE]. CR#1 had a diagnosis which included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness resulting from a stroke). CR#1 was transferred to a local hospital on [DATE] related to a percutaneous gastrostomy endoscopic (PEG) tube replacement (feeding tube replacement). Record review of CR#1's admission MDS assessment, dated 06/03/2025, reflected a BIMS was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. In Section M for skin, he was triggered to have 1 stage 2 pressure ulcer upon admission. Record review of CR#1's comprehensive care, dated 09/26/2025, reflected:Focus: CR#1 has a pressure ulcer to the sacrum, back (2), left ankle, left foot, left heel, Right lower legand right heel related to limited mobility, incontinence, end stage skin failure.Goal: The resident's pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer treatments as ordered and monitor for effectiveness. Record review of CR#1's hospital clinical record, dated 05/27/2025, reflected a pressure ulcer located to the buttock on 05/26/2025, with no orders identified for continued treatment upon discharge. Record review of CR#1's progress notes, dated 05/28/2025 at 9:56 PM by ADON B, read in part, .[CR#1] has dressing to sacral area and has a peg tube. No other skin issues observed to resident. Record review of CR#1's total body skin assessment, dated 05/29/2025, reflected 1 wound with no documentation of the wounds stage or size. Record review of CR#1's MAR for the month of May of 2025 reflected no wound care treatment. Record review of CR#1's May 2025 order summary reflected no orders for wound treatment or wound consult. Record review of CR#1's physician order, dated 06/03/2025, read in part, wound (1) pressure stage 2 coccyx (tailbone). Cleanse with normal saline or wound wash, pat dry, apply comfort foam border 2x (times) weekly and PRN (as needed) if soiled or dislodged. Record review of CR#1's MAR for the month of June of 2025 reflected wound care treatment for a stage 2 coccyx an initial documentation on 06/04/2025. 2. Record review of Resident #2's face sheet, dated 10/09/2025, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Resident #2 had a principal diagnosis which included cerebral infarction, unspecified (stroke), admitting diagnosis of sepsis due to Escherichia Coli (E.Coli a bacteria) and serve sepsis with septic shock (a life-threatening condition that occurs when an infection leads to dangerously low blood pressure and organ failure), and secondary diagnosis of End Stage Renal Disease[ESRD] the final stage of chronic kidney disease, where the kidneys can no longer function adequately to sustain life without treatment) pressure ulcer of sacral region, unstable, and UTI, site not specified. Secondary diagnosis, dated 10/03/2025 for pressure ulcers of right buttock stage 4, left buttock stage 4,right ankle unstageable, left ankle unstageable, left heel unstageable, and other site unstageable. Secondary diagnosis, dated 10/03/2025, for non-pressure chronic ulcer of right heel and midfoot, right foot, and left foot with fat layer exposed. Record review of Resident#2's admission assessment dated [DATE] reflected a BIMS(Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making in Section C. In Section I for active diagnosis, she was triggered for ERSD, Pneumonia, Septicemia, and UTI. In Section M for skin, she was triggered to have 2 stage 4 pressure ulcers, 6 unstageable pressure ulcers, and 5 venous and arterial ulcers present upon admission. In section M she was triggered to have infection of the foot e.g., cellulitis (a common bacterial infection of the skin and underlying tissues), purulent drainage. In Section N for Medications, she was triggered to have antibiotics. In Section O for Special Treatments, Procedures, and Programs, she triggered to have IV medication and hemodialysis. Record review of Resident #2's comprehensive care, dated 10/06/2025, reflected:Focus: Resident #2 had pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, DM, incontinence. Present on admission: Two stage 4, Six unstageable, Five Venous/arterial ulcers, One diabetic foot ulcer. Goal: Resident #2's Pressure ulcer will show signs of healing and remain free from infection by/through review date.Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Focus: Resident #2 is on Antibiotic Therapy r/t sepsis r/t wounds, UTI, and aspiration PNA.Goal: Resident #2 will be free of any discomfort or adverse side effects of antibiotic therapy through the review date.Intervention: Administer medication as ordered. Antibiotics are non-selective and may result in the eradication of beneficial microorganisms and the emergence of undesired ones, causing secondary infections such as oral thrush ( fungal infection of the mouth), colitis (inflammation of the lining of the colon), and vaginitis (an inflammation of the vagina). Any antibiotic may cause diarrhea, nausea, vomiting, anorexia (a serious and potentially life-threatening eating disorder), and hypersensitivity/allergic reactions. Monitor q-shift for adverse reaction. Observe for possible side effects every shift. Report pertinent lab results to MD.Focus: Resident #2 needs hemodialysis MWF r/t renal failure.Goal: The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Intervention: Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis (MWF). Monitor labs and report to doctor as needed. Monitor/document report to MD s/sx of depression. Obtain order for mental health consult if needed. Monitor/document/report to MD PRN any s/sx of infection to access site: Redness, Swelling, warmth or drainage. Monitor/document/report to MD PRN for s/sx of renal insufficiency: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung sounds. Monitor/document/report to MD PRN for s/sx of the following: Bleeding, Hemorrhage, Bacteremia, septic shock. Obtain vital signs and weight per protocol. Report significant changes in pulse, respirations and BP immediately. Record review of Resident #2's comprehensive care plan review with a review, completed date of 10/06/2025, reflected no care plan for pain. Record review of Resident #2's hospital clinical record, dated 09/25/2025, reflected diagnosis of sepsis (a life-threatening condition where the body's extreme response to an infection damages its own tissues and organs) with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pansensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident #2's hospital clinical discharge record, dated 09/29/2025, reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN100 ml with piperacillin-tazobactam (Zosyn) 4.5 (4-0.5) g SOLR 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty: 100 GM, refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident #2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident #2 discharged to treat the wounds. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2PM so she can be admitted to the facility.Tomorrow will be her dialysis day and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning.Record review of Resident #2's facility phone medication order, date 09/30/2025 at 7:15 PM for piperacillin sod-tazobactam (piperacillin sodium-tazobactam sodium) So intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident #2's MAR for the month of September 2025 reflected no Zosyn was administered to Resident #2 on her admission day of 9/30/2025.Record review of Resident #2's initial skin assessment, dated 09/30/2025 at 9:22 PM, by LVN A, read in part, .[Resident #2] had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of the Resident #2's physician order summary report reflected the following orders to treat a DTI to the right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of the Resident #2's physician order summary report reflected that a wound consult was not entered at Resident #2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's hospital records ,dated 09/29/2025, reflected she had the following as needed (PRN) orders for pain:Acetaminophen 650 mg tablet Q 6 hours PRN mild pain.Acetaminophen 650 mg tablet Q 6 hours PRN pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM.Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours PRN for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's MAR, dated 09/01/25, through 09/30/25 reflected Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident #2's facility Order Recap, dated September 2025, reflected an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. Continued record review revealed the order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's MAR for the month of October 2025 reflected Zosyn was administered to Resident #2 on 10/04/2025 at 8:00 PM for the initial dose. Record review of Resident #2's initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 2; Unstageable (Due to necrosis [cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function]) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days.Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days.Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of Resident #2's physician order summary, for October 2025, reflected the orders provided initial wound evaluation and management summary, dated 10/02/2025, completed by Wound Care Doctor A were not entered until 10/04/2025. Record review of Resident #2's MAR, dated 10/01/25, through 10/31/25 reflected the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Records Record review of Resident#2's progress note dated 10/03/2025 at 6:27am and completed by RN A reflected that NP A was notified of change, but there was no information detailing what the change was or orders to address the change. Records record review of Resident#2's SBAR, dated 10/03/2025 at 6:05 AM and completed by RN A, did not reflect specific information of notifying NP A her missed hemodialysis session or orders from NP A to address the missed hemodialysis session. Record reviews of Resident #2's electronic medical record reflect no PAINAD assessments completed for Resident #2 to show that Resident#1 had been assessed for pain. In an interview on 10/08/2025 at 3:09 PM with Treatment Nurse A, she said CR#1 admitted to the facility sometime in May 2025, he had a wound, but she was not sure of the location of the wound. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said wound care was documented the MAR, without an order there would be no way to document wound care treatment, and if the standard of practice was without documentation it did not happen. She said the risk of no wound care treatment from 05/28/2025-06/03/2025 could be the wound deterioration, possible infection, and possible hospitalization. She said to go without wound care treatment from 5/28/2025-06-3-2025 was a significant amount of time. In an interview on 10/08/2025 at 4:49 PM with ADON A, she said she started at the facility on 06/30/2025. She said CR#1 was already admitted to the facility when she started so she was not sure what wounds he had at the time of admission. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented in the MAR, without an order there would be no way to document wound care treatment, and the standard of practice was without documentation it did not happen. She said the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound got worse, became infected and could lead to hospitalization. She said CR#1 did not have orders upon admission to treat the wound on the coccyx on 05/28/2025, orders were entered on 06/03/2025, and initial treatment was completed on 06/04/2025. She said CR#'1s treatment was delayed, placing him at risk of wound worsening, infection, and hospitalization. In an interview on 10/08/2025 at 5:33 PM with DON A, she said she started at the facility on 05/27/2025. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented on the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said residents should have orders upon admission but no later than 24 hours to treat wounds. She said wound care was documented in the MAR, without an order there would be no way to document wound care treatment, and the standard of practice was without documentation, it did not happen. She said she reviewed the clinical record of CR#1, he admitted with a wound to the coccyx on 05/28/2025, there were no orders to treat the wound entered until 06/03/2025, he did not receive initial treatment until 06/04/2025, his treatment was delayed, and he was placed at risk of wound worsening, infection, and hospitalization. In an interview on 10/08/2025 at 6:18 PM with Administrator A, she said residents should have orders upon admission to treat wounds. She said if a resident admitted on [DATE] and did not have orders to treat a wound until 06/03/2025, that would be a delay in treatment. She said the risk to the resident could cause the wound to worsen depending on the clinical condition of the residents and location of wound. In an interview and observation on 10/09/2025 at 10:57 AM of ADON A to perform Resident #2's wound care with assistance from CNA A. ADON A said at the start of the treatment Resident #2 had been medicated for pain about 30-40 minutes prior. Resident #2 was observed to have tolerated the wound care treatment without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle, which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed as if she were in pain. Resdient#2 was not interviewable and non-verbal. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said her clinical impression was that some of Resident #2's wounds were infected at the time of admission, and it was apparent she had recent debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound) of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36 PM with the Medical Director, she said she was the primary physician for Resident #2. She said staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said a wound consult should have been made upon admission, and the orders given after the wound consult should have been entered and carried out. She said that Resident#2 IV antibiotics should have been arranged prior to admission, and if it was not available orders could be arranged to switch to an oral antibiotic until it was available. In a follow up interview on 10/09/2025 at 5:14 PM with ADON A, she said the admitting nurse completed an initial skin assessment at the time of admission. She said the treatment nurse should complete a second skin assessment on new admissions with wounds identified within 24 hours of admissions. She said the treatment nurse should review the facility clinical records and hospital clinical records. She said the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said there should be a clinical review of all new admissions the next business day with Administrator A and clinical department heads present. She said she worked as the treatment nurse on 09/30/2025 and 10/01/2025. She said Resident #2 admitted on [DATE] with wounds. She said she did not complete the second skin assessment for Resident #2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she was not able to finish by the end of her shift. She said ADON B would have been responsible for completing Resident #2's wound care treatment after admission. She said she did not recall if she attended the clinical admitting on 10/01/2025. She said LVN A was responsible for ensuring medications and treatments were reconciled at the time of admission and entering the orders. She said Resident #2 did not have orders to treat all her wounds at the time of admission. She said that Resdient#2 did not have orders treat infections with Zosyn at the time of admission. She said a clinical review of Resident #2's admission should have caught the error. She said the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30 PM with ADON B, she said she worked on 09/30/2025 and 10/01/2025 from 10:00PM -6:00AM. She said she did not assist with the admission of Resident #2, and the admission was completed by LVN A. She said LVN A told her Resident #2 admitted with wounds with treatment orders from the hospital. She said she completed Resident #2's wound care on 10/01/2025. She said no one communicated to her to complete a skin assessment as the treatment nurse for Resident #2. She said she was not the treatment nurse for the facility, but she did help with wound care. She said she started as an ADON on 10/09/2025, prior to that she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In a follow up interview on 10/09/2025 with the DON, she said she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted to the facility on [DATE]. She said there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator A present. She said the clinical review should be to review the admission process for accuracy and correcting errors made. She said she had not completed an assessment of Resident #2 since the time of admission. She said that she was not aware Resident #2 did not have skin assessments completed by a treatment nurse after admission. She said it was the responsibility of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said she was not aware Resident #2 did not have orders to treat all wounds or wound consult upon admission She said that she was not aware of Resident#2 to have not received antibiotics from the time of admission. She said she could not recall if there was a clinical review of Resident #2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41 PM with Administrator A, she said she did not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting. She said she did not believe she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said the DON was the clinical oversight for the facility. She said the DON should review all new admissions, re-admission, change in conditions, and the 24-hour report for accuracy. She said the DON should review all medical clinical records prior to a residents admission. In an observation on 10/10/2025 at 9:32 AM at the beside of Resident #2 revealed the resident was non-verbal or not interviewable. In an interview on 10/10/2025 at 9:38 AM with the in-house Hemodialysis Nurse, she said on 10/03/2025, Resident #2 could not receive hemodialysis due to a change in condition, which was an elevated heart rate around 120 beats each minute, she contacted the Nephrologist who ordered Metoprolol to Resident #2, and she communicated with Resident #2's nurse (name unknown) about the order for Metoprolol. She said Resident #2 was referred back to the facility nurse (name unknown) for further intervention and treatment. She said when a resident did not receive hemodialysis as scheduled, they were usually sent to the hospital to receive hemodialysis. She said she later found out Resident #2 was not sent to the hospital.In a phone interview on 10/10/2025 at 10:05 AM with RN A who worked the 10:00PM-6:00AM, said she notified NP A that Resident #2 had not received her hemodialysis on 10/03/2025, because her hea

Based on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, a residents with pressure ulcers received necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 13 residents (CR #1 and Resident #2) reviewed for pressure ulcers. -The facility failed to treat the wound of CR#1's buttock from admission on [DATE]-[DATE]/2025. 2.--The facility failed to identify and treat the wounds of Resident #2 from admission on [DATE]-[DATE]. An Immediate Jeopardy (IJ) situation was identified on 10/11/2025. While the IJ was removed on 10/20/2025, the facility remained out of compliance, at a scope of pattern with a potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for delayed treatment, worsening of condition, hospitalization, and death. Resident #2 was admitted to the hospital on [DATE] with a critically elevated white blood cell count (WBC), sepsis and had an above the knee amputation of both legs due to gangrene. Findings include: 1. Record review of CR#1's face sheet dated 09/30/2025, reflected he was a [AGE] year-old male, who admitted to the facility on [DATE] with a principal diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis and weakness resulting from a stroke). CR#1 was transferred to a local hospital on [DATE] related to a percutaneous gastrostomy endoscopic (PEG) tube replacement (feeding tube replacement). Record review of CR#1's admission MDS (Minimum Data Set) assessment dated [DATE] reflected a BIMS (Brief Interview for Mental Status) was not available as the resident rarely /never understood with severely impaired cognitive skills for daily decision making. In Section M for skin, he was triggered to have 1 stage 2 pressure ulcer upon admission. Record review of CR#1's comprehensive care dated 09/26/2025 reflected: Focus: CR#1 has a pressure ulcer to sacrum, back (2), left ankle, left foot, left heel, Right lower leg and right heel related to limited mobility, incontinence, end stage skin failure. Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention: Administer treatments as ordered and monitor for effectiveness. Record review of CR#1's hospital clinical record dated 05/27/2025 reflected a pressure ulcer located to the buttock on 05/26/2025. Record review of CR#1's progress notes dated 05/28/2025 9:56pm by ADON B, read in part, .CR#1 has dressing to sacral area and has a peg tube. No other skin issues observed to resident. Record review of CR#1's total body skin assessment dated [DATE] reflected 1 wound. Record review of CR#1's Medication Administration Record (MAR) for the month of May of 2025 reflected no wound care treatment. Record review of CR#1's May 2025 order summary reflected no orders for wound treatment or wound consult. Record review of CR#1's physician order dated 06/03/2025 read in part, wound(1) pressure stage 2 coccyx(tailbone). Cleanse with normal saline or wound wash, pat dry, apply comfort foam border 2x(times) weekly and PRN (as needed) if soiled or dislodged. Record review of CR#1's MAR for the month of June of 2025 reflected wound care treatment for a stage 2 coccyx an initial documentation on 06/04/2025. Record review of Resident #2's admission Record dated 10/22/2025 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. Record review of Resident#2's comprehensive care plan dated 10/06/2025 reflected: Focus: Resident#2 has pressure ulcers and potential for more pressure ulcer development r/t immobility, fragile skin, Diabetes Mellitus (DM), incontinence. Present on admission: Two stage 4, Six unstageable (a type of pressure ulcer or wound that cannot be accurately staged due to the presence of slough [dead, yellow or gray tissue that forms in a wound] or eschar [a layer of dead, dried tissue that forms over a wound]), Five Venous (a chronic open sore that develops when blood pools in the veins of the lower legs)/arterial (a break in the skin that occurs when there is a blockage or narrowing of the arteries) ulcers, One diabetic foot ulcer. Goal: Resident#2's Pressure ulcer will show signs of healing and remain free from infection by/through review date. Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness. Administer protein supplements as ordered. Administer treatments as ordered and monitor for effectiveness. Replace loose or missing dressings PRN. Administer Vitamin C as ordered. Administer Zinc as ordered. Assess/record/monitor wound healing at least weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report declines to the MD. Record review of Resident#2's hospital clinical record dated 09/25/2025 reflected diagnosis of sepsis with fever leukocytosis, multifactorial; infected sacral ulcer/pneumonia, status post septic shock, unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle; not bony involvement, Post E.coli UTI, Right lower lobe/aspiration pneumonia, acute hypoxic respiratory failure, end-stage renal disease on dialysis, peripheral arterial disease, toe gangrene. Plan, Zosyn 2.25g IV every 8 hours for pan sensitive E. coli wound culture plus empirical anaerobic coverage. Anticipate another 2 weeks of IV antibiotics. Record review of Resident#2's hospital clinical discharge record dated 09/29/2025 reflected a discharge diagnosis of sepsis with discharge medication, sodium chloride 0.9% SOLN(solution) 100 ml (Milliliter) with piperacillin-tazobactam (Zosyn)4.5 (4-0.5) g(gram) SOLR(Solution Reconstituted) 4.5g, Inject 4.5g into the vein every 12 (twelve) hours for 14 days qty(quantity): 100 GM(gram), refills: 0. The discharge summary did not give an account of how many wounds were identified while Resident#2 was admitted , the stage of the wounds, or what treatment orders were to continue after Resident#2 discharged to treat the wounds. Record review of Resident #2's hospital clinical record dated 9/30/2025 reflected in part: wound care orders for her sacrum and right lateral ankle/foot. Arterial changes to RLE. Toes continue to harden, gangrenous. Right lateral leg remains purple/black. Gangrene to L 2nd -4th toes.Unstageable sacral ulcer infected status post-surgical debridement 9/16 up to muscle: not bony involvement. Infected sacral ulcer/pneumonia.Post E. Coli UTI. Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2pm so she can be admitted to the facility.[sic]Tomorrow will be her dialysis today and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning. Record review of Resident#2's facility phone medication order date 09/30/2025 at 7:15pm for piperacillin sod-tazobactam ((piperacillin sodium-tazobactam sodium) intravenous solution reconstituted 4.5 (4-0.5) GM (piperacillin sodium-tazobactam sodium) Use 100 gram intravenously every 12 hours for wound infection for 14 days, prescribed by Medial Director and confirmed by LVN B. Record review of Resident#2's MAR for the month of September 2025 revealed no Zosyn administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident#2's MAR for the month of October 2025 reflected Zosyn administered to Resident #2 on 10/04/2025 at 8:00pm for the initial dose. Record review of Resident #2's initial skin assessment dated [DATE] at 9:22pm by LVN A, read in part, .Resident #1 had redness to left abdomen.excoriation to vaginal area and buttocks. Moisture associated skin damage present: Yes; see ulcer assessments for details.Other skin findings: Pressure wound to sacral area, DTI(Deep Tissue Injury) to Right lateral lower leg near ankle, DTI to right heel, DTI to right lateral mid foot, DTI to Right medial ankle, Necrotic digits to all toes of right and left foot, DTI to left lateral front foot and DTI to left lateral mid foot, DTI to left heel and left lateral ankle. Central Cath to upper left chest (for dialysis use) and PEG tube. Record review of the Resident#'2 physician order summary report reflected the following orders to treat a DTI to right lower lateral leg near ankle, right heel, left lateral mid foot, left heel, and left lateral ankle from admission on [DATE] were not entered and implemented until 10/04/2025. Record review of the Resident#'2 physician order summary report reflected a wound consult was not entered at resident#2's admission on [DATE] and was entered an implemented 10/02/2025. Record review of Resident#2's MAR for the month of September 2025 reflected no wound care treatments administered to Resident #2 on her admission day of 9/30/2025. Record review of Resident #2's initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A revealed 14 wound sites, read in part, Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon or bone). Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 2; Unstageable (Due to necrosis (cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function) Right, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 4; Arterial Wound of the Right Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 5; Arterial Wound of the Right Third Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 8; Arterial Wound of the Left Second Toe Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days, Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm /Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days. Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Treatment Plan, Primary Dressing(s) Leptospermum honey apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days; Gauze sponge non-sterile apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days, Negative pressure wound therapy apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days: 125 mm Hg Secondary Dressing(s) Gauze island w/ bdr apply once daily and as needed: if saturated, soiled, or dislodged. For 2 days Peri Wound Treatment Skin prep apply three times per week and as needed: if saturated, soiled, or dislodged. For 30 days. Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Treatment plan, Betadine apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days. Record review of physician order summary for October 2025 reflected that the orders provided initial wound evaluation and management summary dated 10/02/2025 completed by Wound Care Doctor A were not entered until 10/04/2025. In an interview on 10/08/2025 at 3:09pm with Treatment Nurse A, she said that she started at the facility in 2022 as a floor nurse but was promoted to weekend treatment nurse in 2005. She said that CR#1 admitted to the facility sometime in May 2025, he had a wound, but she was not sure of the location of the wound. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound deterioration, possible infection, and possible hospitalization. She said that to go without wound care treatment from 5/28/2025-06/03/2025was a significant amount of time. In an interview on 10/08/2025 at 4:29pm with ADON A, she said that she started at the facility on 06/30/2025. She said that CR#1 was already admitted to the facility when she started so she was not sure what wounds he had at the time of admission. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that the risk of no wound care treatment from 05/28/2025-06/03/2025 could be that the wound gets worse, becomes infected, and could lead to hospitalization. She said that CR#1 did not have orders upon admission to treat wound on the coccyx on 05/28/2025, orders were entered on 06/03/2025, and initial treatment was completed on 06/04/2025. She said that CR#'1s treatment was delayed placing him at risk. In an interview on 10/08/2025 at 5:33pm with DON A, she said that she started at the facility on 05/27/2025. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented on the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that residents should have orders upon admission but no later than 24 hours to treat wounds. She said that wound care was documented the MAR, without an order there would be no way to document wound care treatment, and the standard of practice is without documentation it did not happen. She said that she reviewed clinical record of CR#1, he admitted with a wound to the coccyx on 05/28/2025, there were no orders to treat the wound entered until 06/03/2025, he did not receive initial treatment until 06/04/2025, his treatment was delayed, and he was placed at risk. In an interview on 10/08/2025 at 6:18pm with the Administrator, she said that residents should have orders upon admission to treat wounds. She said that if a resident admitted [DATE] and did not have orders to treat a wound until 06/03/2025 that would be a delay in treatment. She said that the risk to the residents could be that the wound could worsen depending on the clinical condition of the residents and location of wound. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. In an interview on 10/09/2025 at 2:46pm with LVN A, she said that she was the admitting nurse for Resident#2 on 09/30/2025. She said that she completed a skin assessment on Resident#2 at the time of admission, she had multiple wounds at the time of the admission, and she did not recall the location of the wounds. She said that she reconciled the medication list and treatments for the wounds with the on-call nurse practitioner for the primary care physician, and the nurse practitioner gave orders to continue all treatments and medications as detailed in the medical records until the next rounding day. She said that she enlisted the help of LVN B to help her enter the medications and treatments as ordered by the nurse practitioner at the time of Resident#2's admission. She said that Resident#2's hospital medical records said that she was continue with an antibiotic Zosyn every 12 hours via a dialysis port, but she was unsure what type of infection the Zosyn was to treat. She said that her clinical impression was that some of Resident#2's wounds were infected at the time of admission, and it was apparent that she had recent debridement of the wounds prior to being discharged from the hospital. In an interview on 10/09/2025 at 4:36pm with the Medical Director, she said that she was the primary physician for both CR#1 and Resident #2. She said that staff should notify the primary care physician at the time of admission to obtain orders for medications and treatments. She said that she did not want to speak on potential risks to residents if staff did not obtain medication and treatment orders at the time of admission. She said that Resident #2 IV antibiotics should be arranged prior to a resident's admission, and if it's not available orders could be arranged to switch to an oral antibiotic until it was available. She said that a wound consult should be made upon admission, and orders should be given after the wound consult should be entered and carried out. In a follow up interview on 10/09/2025 at 5:14pm with ADON A, she said that that the admitting nurse completes an initial skin assessment at the time of admission. She said that the treatment nurse should complete a second skin assessment on new admission with wounds identified within 24 hours of admissions. She said that the treatment nurse should review the facility clinical records and hospital clinical records. She said that the treatment should be reviewing the admission nurse work for accuracy and correcting any errors made. She said that there should be a clinical review of all new admissions the next business day with the Administrator and clinical department heads present. She said that she worked as treatment nurse on 09/30/2025 and 10/01/2025. She said that Resident #2 was admitted on [DATE] with wounds, and orders for Zosyn. She could not recall if the order for Zosyn was to treat a wound infection or UTI. She said that she did not complete the second skin assessment for Resident #2 at the time of admission, she asked ADON B to complete the second skin assessment, and ADON B would help complete treatment duties when she is not able to finish by the end of her shift. She said that ADON B would have been responsible for complete Resident #2's wound care treatment after admission. She said that she did not recall if she attended the clinical admitting on 10/01/2025. She said that LVN A was responsible for ensuring that medications and treatments were reconciled at the time of admission and entering the orders. She said that Resdient#2 did not have orders treat all her wounds or Zosyn at the time of admission. She said that a clinical review of Resident#2's admission should have caught the error. She said that the risk to Resident#2 was the worsening of wounds and infection. In an interview on 10/09/2025 at 5:30pm with ADON B, she said that she worked on 09/30/2025 and 10/01/2025 from 10:00pm -6:00am. She said that she did not assist with the admission of Resident#2, and the admission was completed by LVN A. She said that LVN A did tell her that Resident #2 was admitted with wounds with treatment orders from the hospital. She said that she did complete Resident #2's wound care on 10/01/2025. She said that no one communicated to her to complete a skin assessment as the treatment nurse for Resident #2. She said that she is not the treatment nurse for the facility, but she does help with wound care. She said that she started as an ADON on 10/09/2025, prior to she was a floor nurse, she was not sure who was responsible for completing wound care at the facility, and she was not sure what the facility was communicating her role to be at the facility prior to 10/09/2025. In a follow up interview on 10/09/2025 with the DON, she said that she worked on 09/30/2025 and 10/01/2025, and Resident #2 admitted on [DATE]. She said that there should be a clinical review of all new admissions on the next business day after the admission with the clinical department heads and Administrator present. She said that the clinical review should be to review the admission process for accuracy and correcting errors made. She said that she had not completed an assessment of Resident #2 since the time of admission. She said that she was not aware of Resident#2 having not received antibiotics from the time of admission. She said that she was not aware that Resident #2 did not have skin assessment completed by a treatment nurse after admission. She said that it was responsibility of both ADON A and ADON B to complete wound care in the absence of a permanent treatment nurse. She said that she was not aware that resident did not have orders to treat all wounds or wound consult upon admission. She said that she was not aware that Resident #2 had missed a dialysis treatment after admission. She said that she could not recall if there was a clinical review of Resident #2 after admission, and if there was a review then admission errors would have been caught and corrected. In an interview on 10/09/2025 at 6:41pm with the Administrator, she said that she does not always stay for daily clinical meetings with the clinical department heads after the daily stand-up meeting. She said that she did not believe that she participated in the clinical meeting on 10/01/2025, and she took a phone call. She said that the DON was the clinical oversight for the facility. She said that the DON should review all new admissions, re-admission, change in conditions, and the 24-hour report for accuracy. She said that the DON should review all medical clinical records prior to a residents admission. In an interview on 10/10/2025 at 11:10am with NP B, he said that he is the nurse practitioner for the facilities Medical Director. He said that Resident#2 admitted on [DATE] while he was off, NP B covered for him, and NP B saw Resident#2 on 10/01/2025. He said that Resident#2 admitted with wounds, and she was being treated with IV antibiotics, Zosyn, for UTI and Wound culture for E. Coli while in hospital, and the Zosyn was to continue for 2 weeks after discharge. He said that he was asked to see resident number today on 10/10/2025 by the Medical Director and that was his first time meeting Resident#2. He was unsure when the Resident#2 received the first dosage of the Zosyn, but it should start no later than the next day after admission. He said that his expectation would be that all medications and treatments start no later than the next day after the order is given. He said that the risk is that conditions or infections could worsen. He said that it was his expectation that a physician or nurse practitioner be notified when medications were not available to seek additional orders to treat. He said that if he had been notified that Resident#2's Zosyn was not available he would have send her back to the hospital, as there would be no reason for her to remain in the building without the medications, and the risk to Resident#2 would have been the infection could have worsen. He said that it was important for staff to notify a physician of wounds upon admission and once identified. He said that the standards were to continue with orders from the hospital until a wound care physician can take over or the primary physician makes changes to the treatment from the hospital. In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he would have decided on a different treatment plan. He said that he was not contacted to address interventions for a missed hemodialysis on 10/03/2025, he was notified of an elevated heart rate during dialysis that was addressed by another doctor. He said that he would not speak on risk to residents, or if Resident#2 should have been sent to the hospital. He said that his expectation is that staff make enter orders from the time of admission, follow orders, an

Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 13 residents (Resident #2) reviewed for pain. -The facility failed to ensure that pain management was provided for Resident #2, who was crying in pain, during the treatment of her 14 individual wounds. -The facility failed to assess Resident #2 accurately and appropriately, for pain prior to Resident #2 receiving wound care treatments for 14 separate wounds. -The facility failed to provide timely medication interventions for Resident #2's pain management for daily wound care treatments of her 14 individual wounds. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 6:39 PM. While the Immediacy was removed on 10/19/2025 at 5:44 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. These failures placed residents at risk of increased or unmanaged pain and actual harm. Findings Include: Resident #2 Record review of Resident #2's admission Record dated 10/22/2025 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. Record review of Section V of the MDS related to Resident #2's Care Area Assessment Summary (CAA) had no care area triggers for pain and had no care planning decision made for pain. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed no care plan for pain. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed she had the following as needed (prn) orders for pain: Acetaminophen 650 mg tablet Q 6 hours prn mild pain. Acetaminophen 650 mg tablet Q 6 hours prn pain or temperature 100.4 or greater which Resident #2 was documented as having received on 9/28/25 at 5:28 PM. Hydromorphone PF Dilaudid 0.5mg IV Q 4 hours prn for severe pain which Resident #2 was documented as having received on 9/28/25 at 12:36 PM. Record review of Resident #2's facility Order Recap dated September 2025 revealed an order for Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. Continued record review revealed the order was for an oral/by mouth administration and Resident #2 was a gastrostomy status resident. Record review of Resident #2's Medication Administration Record (MAR) dated September 1, 2025, through September 30,2025 revealed Resident #2 did not receive any Acetaminophen during the month of September. Record review of Resident #2's MAR dated October 1, 2025, through October 31, 2025, revealed the following order: Acetaminophen oral tablet 325 MG Give 2 tablets by mouth every 6 hours as needed for pain. D/C Date 10/10/2025. Resident #2 did not receive this medication. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. Observation and interview on 10/10/2025 at 4:59 PM with ADON A and DON of wound care performed on Resident #2. ADON A was assisted by MA E. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said yes about 30-40 minutes ago. When asked how she assessed Resident #2 for pain, ADON A said she used the PAINAD facial expression tool. The wound care treatments began with Resident #2's lower extremities. During the observation, the DON came to the bedside to also observe Resident #2's wounds for the first time since her admission on [DATE]. ADON A began removing the cling gauze wrap from Resident #2's left and right lower extremities by using wound care scissors to cut away at the tightly wrapped bandages. Resident #2 was observed by both surveyor at the bedside, wincing repeatedly each time the bandage was moved or cut which prompted this surveyor to ask ADON A if she ever used any saline or solution to moisten and loosen the adhered bandages so as to ease in the removal of the bandages so there would be less pulling, ripping or tugging at Resident #2's delicate skin. ADON A replied quickly and stated, oh yes and then began spraying a liquid solution onto the adhered bandages while still cutting. There was some brownish drainage, skin and mucous like debris observed on the inside of the bandages as ADON A continued to peel, tear, and cut the bandages away from Resident #2's right lower leg and foot. Resident #2 began to inhale and exhale deeply and became tearful, with tears brimming in her eyes. ADON A had her back to Resident #2's face and appeared focused on her wound care task, while MA A tried to speak to Resident #2 softly and reassure her, however, neither staff member stopped the procedure to reassess Resident #2 for pain. Surveyor stopped ADON A and asked what pain medication Resident #2 had been given prior to the procedure and ADON A replied Tylenol, to which surveyor replied, regular strength, to which ADON A replied, extra strength. Both surveyors requested wound care treatment be stopped immediately and DON also said they would stop the treatment, notify the physician, and get an order for a different and or stronger pain medication. Record review post observation revealed Resident #2 had received no Tylenol regular or extra strength on 10/09/2025 or 10/10/2025. Continued record review of Resident #2's MAR dated October 1, 2025, through October 31, 2025, revealed the following orders: Acetaminophen Oral Tablet 325 MG (Acetaminophen) Give 2 tablet via G-Tube every 6 hours as needed for pain. Continued record review of Resident #2's, physician orders and MARs for the months of September 2025 and October 2025, revealed she had no other pain medication ordered and had not received any pain medication from her admission on [DATE] through 10/10/2025. Interview on 10/10/2025 at 5:26 pm with facility Administrator who was advised of the wound care observation of Resident #2 and the major concerns regarding the lack of any pain management for Resident #2 since her facility admission on [DATE]. The Administrator said the concerns were clinical concerns and she would have to speak with the DON to gather more information on the situation. The Administrator said she had no dealings with and did not handle anything to do with the clinical side of things, such as medication, pain management, or wound care because she was not a clinician. The Administrator said the responsibility for those things would be for the DON and she would need to follow up with the DON to determine what happened. Telephone interview on 10/10/2025 at 5:33 pm with Wound Care Doctor A who said he was notified on 10/02/2025 of Resident #2's admission and need for a wound care consultation. Wound Care Doctor A said the first time he examined or assessed Resident #2 was on 10/02/2025 and from what he could remember, she admitted with multiple extensive wounds, including her sacrum and buttocks and her toes were at risk of auto (self) amputation. Wound Care Doctor A said he did not ever see any evidence of Resident #2 being in pain during his assessments or treatments of her multiple wounds. Wound Care Doctor A said he had not prescribed anything for Resident #2's pain because he had not ever witnessed any signs or symptoms of her being in pain and had not been notified by staff that the resident ever had signs or symptoms of pain. Wound Care Doctor A said that in most instances he would defer to the resident's attending physician for any pain medication orders. When asked if he thought a person with 14 wounds could have pain, he said pain was subjective and he would not speculate. Record review of Wound Care Doctor A's progress note dated 10/2/25 for the initial assessment and treatment of Resident #2's wounds revealed the following 14 wound sites: Site 1; Diabetic Wound of the Right Heel Full thickness (refers to a deep wound that extends through all layers of the skin and may also involve deeper structures such as muscle, tendon, or bone) . Site 2; Unstageable (Due to necrosis (cell death that occurs when most or all of the cells in an organ or tissue are irreversibly damaged and lose their normal function) Right, Lateral Ankle Full Thickness. Site 3; Arterial Wound (a type of open sore that develops when blood flow to the affected area is reduced) of the Right First Toe Full Thickness. Site 4; Arterial Wound of the Right Second Toe Full Thickness. Site 5; Arterial Wound of the Right Third Toe Full Thickness. Site 6; Arterial Wound of the Right Lateral Foot Full Thickness. Site 7; Unstageable (Due to Necrosis) of the Left Heel Full Thickness. Site 8; Arterial Wound of the Left Second Toe Full Thickness. Site 9; Stage 4 Pressure Wound of the Right Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Site 10; Stage 4 Pressure Wound of the Left Buttock Full Thickness with a Surgical Excisional Debridement Procedure (a procedure where a surgeon uses a scalpel to cut away and remove dead or contaminated tissue from a wound until healthy, viable tissue is exposed), performed on the site. Site 11; Unstageable (Due to Necrosis) of the Right, Medial Ankle Full Thickness. Site 12; Unstageable (Due to Necrosis) of the Right, Medial Foot Full Thickness. Site 13; Unstageable (Due to Necrosis) of the Left, Lateral Ankle Full Thickness. Site 14; Unstageable (Due to Necrosis) of the Right, Lateral Foot Full Thickness. Interview with DON on 10/11/2025 at 10:00am who said she was unaware of any issues with Resident #2's pain medication or lack of receiving pain medication for wound care. The DON said they had followed up on 10/10/205 after the observation and spoke with Resident #2's doctor and Resident #2 had a scheduled and prn order for Acetaminophen and had only prescribed Acetaminophen because she could not take NSAIDS (Non-Steroidal Anti-Inflammatory Drug) because of her hemodialysis status and history of end stage renal disease, as these drugs can cause severe kidney damage and dangerous complications. The DON said Resident #2 should have been medicated for pain prior to the treatment procedure and did not know why or how her pain management had been missed all this time. The DON said it was the responsibility of the clinical team to ensure residents are managed properly for pain. The DON said she was part of the clinical team and was partially responsible for ensuring residents had effective pain management. The DON said she was unsure if Resident #2 had been care planned for pain but said she should be. Interview on 10/11/2025 at 10:12 am with ADON A who said she believed Resident #2 had received pain medication prior to both wound care observation on 10/09/2025 and 10/10/2025. ADON A said that there was no pain medications listed for her to administer prior to wound care and only her treatments populated in the computer system for her to document on. ADON A said she was under the impression that LVN C and LVN D had premedicated Resident #2 on both 10/09/2025 and on 10/10/2025 because she told them she was going to perform wound care. When asked where the PAINAD assessments for Resident #2 could be located in the electronic medical record, ADON A said that she had looked for one and could not locate the assessment template in the facility's computerized system. ADON A said she assessed Resident #2 visually for PAINAD signs and symptoms of pain but never actually documented on an assessment form, and 10/10/2025 was the first time she ever saw Resident #2 react in pain to wound care treatments she provided. ADON A said Resident #2 should have been medicated for pain because she had a lot of wounds that could potentially be painful. ADON A said she was unsure if Resident #2 had been care planned for pain. Interview with LVN D on 10/11/2025 at 3:15 pm regarding pain medication administration for Resident #2 prior to wound care on 10/10/2025. LVN D said ADON A never asked him to premedicate Resident #2 prior to wound care. LVN D said he had never given Resident #2 any pain medication since her admission on [DATE] during his shifts. LVN D said Resident #2 only received medication from licensed nurses because of her gastrostomy tube status. LVN D said that Resident #2 never indicated she was in any pain when he provided care and that no CNA or MA staff had ever reported to him that Resident #2 was in pain. LVN D said he was unsure if Resident #2 always had pain medications ordered before, but he was sure she had orders for scheduled and prn pain medications now. LVN D said he used the PAINAD facial expression pain scale to assess Resident #2 because she was non-verbal but said he could not tell surveyor how to locate a copy of the form in the electronic medical record. Interview with LVN C on 10/13/2025 at 2:15pm regarding pain medication for Resident #2 on 10/09/2025. LVN C said she was never asked by ADON A to give Resident #2 any pain medication and had not given Resident #2 any pain medication. LVN C said Resident #2 received all her medication through her gastrostomy tube, so only the charge nurses could give pain medication. LVN C said she never observed Resident #2 having any signs or symptoms of pain but if she did, she should be medicated. LVN C said she was unsure if Resident #2 was care planned for pain. LVN C said Resident #2 had new orders for pain medications now and was unsure what the orders had been previously. LVN C said they assessed Resident #2 using a facial expression pain scale and said the assessment tool pops up in the MAR just prior to any pain medication administration but did not know how to print out the assessment tool or access it outside of the medication administration times. LVN C said the only time she had seen the tool was right before a pain medication would be given. Interview with Medical Director on 10/13/2025 at 4:00pm who said she was the attending physician for Resident #2. The Medical Director said they were contacted by the facility late Friday 10/10/2025 and Resident #2 was reassessed for pain, and she gave a new order for the Tylenol to be scheduled every 8 hours instead of just prn. The Medical Director said they conducted a virtual visit with Resident #2 on Saturday 10/11/2025 and asked the male charge nurse about the assessment. The Medical Director said initially she would only prescribe Tylenol because of Resident #2's hemodialysis dependence and potential risk of medication not being processed or excreted properly. The Medical Director said she ordered a very small trial dose of an opioid analgesic Tramadol but was starting the resident on 1/2 of the 25 mg dose for a dose of 12.5 mg so the resident could be watched and reassessed properly. When asked if she thought Resident # 2 should have had stronger and or scheduled pain medication for the daily wound care treatments, of her 14 separate wounds, the Medical Director said pain was subjective and she would not speculate, but staff should have been assessing and evaluating the resident for pain. The Medical Director said no one had notified her prior to 10/10/2025 that Resident #2 had any signs or symptoms of pain and that once she was notified Resident #2 was evaluated/re-evaluated and additional pain management interventions were ordered and implemented. Record review of facility policy procedure titled Pain Management, Assessment Scale revealed in part: Policy Complaints of pain will be assessed accordingly by the nurse and effectively managed through. prescribed medications, and comfort measures, and all available resources of the facility. Goals 5. Cognitively impaired residents will demonstrate actions of pain relief. Complaints of pain will be assessed accordingly by the nurse and effectively managed through. prescribed medications, and comfort measures, and all available resources of the facility. Procedure 1. Assess resident's physical symptoms of pain, physical complaints, and daily activities. Pain questions based on a resident's communication ability were included in the Admission/readmission and Weekly Nursing Summary. If a resident is non-verbal, the questions will be a PAINAD assessment. There is no QM criteria for a resident who is non-verbal. If a resident scores 7-10 on the PAINAD scale, then a (sic)PAIND SBAR will be triggered. It is directed toward residents who are non-verbal or cannot communicate. Administer pain medications as prescribed. Monitor and record medication's effectiveness and side effects. PRN - if the resident complains of pain the nurse will assess, implement relief measures as ordered and/or care planned. This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 6:39 pm. The following Plan of Removal (POR) submitted by the facility was accepted on 10/12/2025 at 1:08 p.m. The plan of removal reflected the following: Facility Name: Date: October 12th, 2025 IJ Component: F697: Quality of care: Pain Management Facility failed to ensure that pain management was provided for Resident #2. During an observation of Resident #2's wound care on 10/10/25, Resident #2 was observed exhibiting signs/symptoms of pain. Immediate Actions: The treatment where the resident was experiencing pain on 10/10/2025 was stopped until adequate pain relief could be achieved. Primary care provider was contacted by the director of nurses on 10/11/2025 and Tylenol order changed to Extra Strength 650 mg every 8 hours scheduled and an additional dose 30 minutes prior to wound care. The Primary care provider stated that the resident was not eligible for narcotic pain relief due to renal failure. Facility Plan to ensure compliance: 100% review of residents receiving wound care for PRN pain medication orders that may be given 30 minutes prior to wound care was completed on 10/11/2025 by Regional Compliance nurse/DON/Designee. 12 of 13 residents identified requiring wound care received new orders/order clarifications to ensure adequate pain management prior to wound care from audit completed 10/11/25. 1 resident identified in the audit has an allergy to acetaminophen. Care plans for 13 of 13 facility residents with wounds were updated on 10/12/25 by Regional Compliance Nurse and DON with interventions to monitor, assess, and report pain during care, including wound care, and what to do if pain management is not effective. Regional Compliance Nurse provided in-service to DON/ADON on 10/11/2025 regarding: Pain management during care and procedures following facility's policy for enforcement, requiring no change in company policy as the policy was effective but not being followed. Communication with medical provider for any resident that is experiencing uncontrolled pain during care and/or procedures using the SBAR as communication tool. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/11/25 regarding pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. Goal for completion of this education to be completed by end of day on 10/12/25. All nurses (LVN/RNs), including PRN nurses, who are not in serviced by 10/12/25 will not be allowed to provide resident care until training has been completed. 6. The Medical Director was notified by the Administrator on 10/11/25 at 7:51pm regarding the immediate jeopardy citation. 7. An Ad-hoc QAPI meeting was held on 10/12/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will observe wound care, Mon-Fri, x 4 weeks to ensure any residents that is receiving wound care receive effective pain management during the procedure. DON/Designee will review order listing report in point click care (facility electronic medical record) daily, Mon-Fri x4 weeks to see any new wound care orders and ensure that pain management orders are in place. The Plan of Removal was confirmed for the IJ by monitoring from 10/11/2025 through 10/19/2025 as follows: On 10/10/2025 at 4:59 p.m., request was made with the DON to review the pain management and orders for Resident #2. On 10/10/2025 at 5:26 p.m., a request was made with the Administrator to review the pain management for Resident #2. The Administrator said she was not clinical and would have to discuss with the DON. During an interview with DON at 10:00 a.m. on 10/11/2025 she said she was unaware that Resident #2 had no correct orders for pain medications and had not received pain medication prior to daily wound care treatments until the shared observation of wound care on 10/10/2025. During an interview with ADON A at 10:12 am on 10/11/2025 she said she was under the impression that Resident #2 had received pain medication prior to wound care on 10/9/25 and 10/10/2025 because she had told the charge nurses to give it. ADON A could not articulate or show examples of PAINAD assessment tool she used to assess Resident #2 for pain on 10/09/2025 or 10/10/2025 and clarified that she was not the one administering pain medications. Interviews with LVN D on 10/11/2025 at 3:15 pm he said he never observed Resident #2 in pain and that ADON A had not asked him to medicate Resident #2 prior to wound care or at any other time. LVN D said he had never administered pain medication to Resident #2. In an interview on 10/12/2025 with licensed nurses who work the 6:00am-2:00pm, at 2:03 p.m., who were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. Treatment Nurse A, ADON A, LVN B and LVN D said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. On 10/12/2025 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the pain medication orders for Resident #2 as she had not received her pain medication as ordered that day. In an interview on 10/13/2025 at 3:18 pm with licensed nurses who worked the 2:00pm-10:00pm shift, who were all knowledgeable of the step-by-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. LVN C and LVN G said that for verbal residents they can assess pain on a scale of 1-10 and for non-verbal residents they can assess pain using a PAINAD scale for facial expressions. All licensed nurses gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that they should evaluate for any pain signs or symptoms prior to, during and after a procedure or treatment. All licensed staff at that time said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, they would initiate SBAR for pain and notify the MD and RP for the resident. In an interview on 10/13/2025 at 4:00 PM the Medical Director, who said that she was notified about the IJ being called, and she had been included on the POR. She said that all treatments and care should have orders, should be documented, and standard. On 10/13/25 at 5:07pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. In an interview on 10/14/2025 at 2:13 pm with MDS Coordinator, who said that she worked full time Monday through Friday on the day shift. She said she was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy or fast, wincing, and flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, they were to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor B's visit on 10/13/25, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to the hospital on [DATE]. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. On 10/15/2025 at 4:44pm a request was made with the Administrator, DON, Corporate and Regional staff to review enteral feeding orders and medication orders for Resident #34 who was a new admission to the facility on [DATE]. Observations on 10/16/2025 at 6:00 a.m.- 2:00 p.m. shift of 3 out of 5 residents for wound care, Resident #11, Resident #12, and Resident #20 who did not have adequate pain management prior to or during the wound observations and wound care treatments needed to be stopped.

Based on interview and record review the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice for 1 of 4 residents (Resident #2). The facility to ensure that Resident #2 received hemodialysis as ordered on 10/03/2025, which resulted in her not receiving any hemodialysis for a total of four days. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 PM. While the Immediacy was removed on 10/16/2025 at 7:43 PM, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure placed residents at risk for delayed treatments, and actual harm. Findings Include: Resident #2 Record review of Resident #2's admission Record dated 10/22/25 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section I for an active diagnosis of Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD). Record review of Section O of the MDS for Special Treatments, Procedures, and Programs was coded for Dialysis while a resident. Record review of Resident #2's comprehensive care plan review with a last care plan review completed date of 10/06/2025 revealed in part: .Focus.Resident #2 needs hemodialysis MWF r/t renal failure.Goal.The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date.Target Date: 10/12/2025.Interventions/Tasks.obtain vital signs and weight per protocol. Report significant changes in pulse, respiration, and B/P immediately. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed the following entry: Assessment and Plan.1. ESRD on HD.Resident #2 has been getting HD TTS.Resident #2 pending DC to skilled nursing (out of state).However, unable to DC today because she needs to leave early enough to arrive there before 2pm so she can be admitted to the facility.Tomorrow will be her dialysis today and she will most likely not be able to DC in time if we do dialysis tomorrow. I will run her dialysis today and that way she will not need dialysis tomorrow.I have discussed with dialysis nurse that the patient will have dialysis orders for today to help facilitate her discharge in the morning. [sic] Continued record review revealed Resident #2 had a Dialysis Central Line Catheter Tunneled Right Subclavian dialysis access site. (A long flexible, hollow tube that is inserted into the large subclavian vein (a large deep vein located on each side of the body) beneath the right collar bone and then tunneled under the skin to an exit port, typically on the chest wall). Record review of Resident #2's progress note dated 10/03/2025 and created by RN A at 6:27 am revealed the following entry: .Observed in bed resting comfortably this morning. Vital signs are Temp:97.6, RR: 20, Pulse 106, B/P: 126/66, POX % is 98% on room air. No distress noted. NP A [sic]notified this morning about the situation/and the change. Resident RP. was called and notified also. Continued record review at the bottom of the entry for .Show on Shift Report, show on 24 Hour Report, Show on MD/Nursing Communication Report were unchecked and remained blank. Record review on 10/09/2025 at 11:48am of Resident #2's progress notes revealed she received in-house hemodialysis as prescribed on 10/01/2025.Record review on 10/09/2025 at 11:55 am of Resident #2's SBAR by RN A dated 10/03/2025 at 5:27 am revealed the following: I am contacting you about the following (select all that apply) .5. Cardiovascular change.14. Other.Pulse 123.5c. Describe symptoms or sign Increased pulse rate of 112.14. Other N/A.R. Request .1. I suggest or request (Check all that apply) .Monitor vital signs (box checked) .5. Provide visit (MD/NP/PA) (box was checked) .3. Date and time MD or NP notified 10/03/2025 05:50 am.1. Follow-up Orders.1. Note any new orders from the MD or NP.Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100. The document was signed and completed by RN A on 10/09/2025. Telephone interview on 10/10/2025 at 10:05 am with RN A who worked overnight shift 10 pm to 6 am and was the charge nurse assigned to Resident #2 the morning of 10/03/2025. RN A said she notified NP A that Resident #2 had not received her hemodialysis on that Friday, 10/3/25, because her HR was too high. RN A said NP A gave an order to re-evaluate Resident #2's vital signs and heart rate within an hour and call him back. When asked if RN A re-evaluated Resident #2's heart rate and called NP A back as ordered, she said it was at the end of her shift. When asked if she followed NP A's order, she said she did retake Resident #2's heart rate but it remained high, so she sent a text to NP A to notify him that Resident #2's HR remained elevated, but she did not recall if NP A ever responded or if she received any orders to administer medications to Resident #2. When asked about the Metoprolol order she documented in Resident #2's SBAR, Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100. RN A said she never administered any medication to Resident #2 because it was the end of her shift and that the Hemodialysis nurse was the one who gave Resident #2 Metoprolol prior to sending her back to the unit without dialysis. When asked if RN A could send surveyor a copy of the text message she sent to NP A, RN A said she would have to look for it. RN A again, said that she could not recall if NP A ever replied and when asked why she documented in Resident #2's SBAR dated 10/3/25 that she had spoken with NP A and received orders for medication Metoprolol, RN A did not reply or respond, she just repeated that this all happened at the end of her 10pm-6am shift and she gave report to the on-coming nurse about Resident #2's elevated HR and missed dialysis. RN A said she could not recall if she specifically asked NP A about any orders for Resident #2 to receive dialysis or an alternate intervention, RN A said she did not remember which nurse she gave report to about Resident #2 not receiving Dialysis and could not recall if she placed any of that information on the facility 24 hour communication report. RN A said she either told ADON A or LVN D about the missed dialysis and elevated HR, but she was unsure. Record review of facility 24 Hour report dated 10/03/2025 on 10/09/2025 at 3:44pm revealed no documentation of note from RN A about Resident #2's missed dialysis or change in condition/SBAR and under the Weights and Vitals section if the entry Pulse read None entered. Record review on 10/09/2025 at 2:47 pm of Resident #2's MAR dated October 1,2025 through 10/31/2025, revealed Metoprolol Succinate Oral Capsule ER 24-hour 25 MG (Metoprolol Succinate) Give 1 capsule via PEG Tube one time a day for HTN/Increased HR> 100. Hold for HR < 100, was not administered by any facility staff on 10/03/2025. Interview with DON on 10/09/2025 at 2:50 pm she said she was unaware that Resident #2 had not received dialysis on 10/03/2025. When asked if she should have known that Resident #2 had not received dialysis on 10/03/2025 the DON said that normally if a dialysis session was missed the resident would make it up on the next dialysis day. The DON said that normally the dialysis MD would order and have dialysis staff/nurse administer any medications for any altered vital signs. The DON said that there should be a clinical review each business day to address any new concerns, change in conditions, 24-hour reports, and speaking with direct care staff to ensure that residents with orders for hemodialysis receive treatments. She said that she was not aware that there were any concerns with Resident#2's receiving hemodialysis. She said that a nurse should notify a physician if a resident does not complete hemodialysis so that the physician can give interventions. The DON said Resident #2's dialysis MD would normally agree to have any IV meds administered through the dialysis port/shunt or site to save resident vasculature meaning only one access site in case of dialysis shunt failure or if the shunt site needed to be changed. Using only the dialysis shunt site would allow for a resident to have multiple sites in their arms/hands etc. The DON said she would have to look into why Resident #2 did not have any dialysis from Wed 10/01/2025 until Monday 10/06/2025. The DON said the last QAPI was last Thursday, and the facility had monthly QAPI's and weekly SOC's, (standards of care). The DON said she could not recall if she reviewed Resident #2's clinical hospital records prior to her admission but that was part of the admission process, so she most likely did. The DON said she could not recall if they discussed Resident #2 in any morning stand up or weekly SOC but since Resident #2 was admitted on [DATE] they would not have discussed any issues regarding the resident yet for QAPI. The DON said they would most likely discuss Resident #2 in this week's SOC meeting. Brief interview with ADON A on 10/10/2025 at 2:00 pm who said she did not recall speaking with RN A specifically about any orders or missed dialysis interventions for Resident #2 on that day. ADON A said she did recall discussing the resident's elevated heart rate and missed dialysis session after the fact. Interview with LVN D on 10/10/2025 at 2:13pm who said he had no memory of RN A speaking to him about Resident #2 and any missed dialysis or elevated heart rate. LVN D said he heard something about the situation later but never spoke directly with RN A or NP A about getting orders for missed dialysis intervention. Interview on 10/10/2025 at 9:38 am with Hemodialysis Nurse who said she recalled and was familiar with Resident #2. Hemodialysis Nurse said she remembered Resident #2 having a change in condition during one of her dialysis sessions and not being able to receive hemodialysis that day because of an elevated HR around 120 beats per min. The Hemodialysis nurse said that Resident #2 had an early chair time of around 4-5am and that Resident #2 was on a MWF dialysis schedule. The Hemodialysis nurse said that on 10/03/2025 Resident #2 could not get dialysis because of an elevated HR in the 120's and she called Nephrologist for orders and intervention. The Hemodialysis Nurse said she tried various interventions, including medication Metoprolol, as ordered, to get Resident #2's HR down so she could safely receive dialysis, but the interventions were unsuccessful. The Hemodialysis Nurse said she had to refer Resident #2 back to her charge nurse around 5 am because her HR remained outside of the safety parameters for her to receive dialysis. The Hemodialysis nurse said that she communicated with Resident #2's charge nurse about the medication Metoprolol that had been given to Resident #2, while she was in dialysis, per Nephrologist's order. The Hemodialysis nurse said it was not recommended for residents/patients to miss dialysis. The Hemodialysis Nurse said she would have definitely communicated the missed dialysis treatment to Resident #2's attending MD/NP because usually the doctor would send the resident to the hospital to receive dialysis, so they did not miss a treatment. The Hemodialysis nurse said she only found out that Resident #2 never went to the hospital after the fact on the following Monday, 10/06/2025, and was concerned that Resident #2 had not received dialysis for 4 days. In an interview with NP B on 10/10/2025 at 10:25 am who said he was not at work on 10/03/2025 and was not notified that Resident #2 had not received her dialysis. NP B said that the physician should be notified so they could give an order if a resident had a change in condition or anything that could affect a resident not receiving dialysis. NP B said that usually if a resident misses dialysis they wound be sent to the hospital to receive dialysis. Telephone interview with NP A on 10/10/25 at 11:33 am said he was covering NP B for one week, from 09/29/20255 through 10/03/2025, and he came to see Resident #2 on 10/01/2025 within 24 hours of her facility admission. NP A said he was notified on 10/3/25 that Resident #2 had an elevated heart rate while at dialysis and that they were unable to continue dialysis that day. NP A said he called the facility three times to provide orders but there was no answer. NP A said when he finally reached a nurse, the nurse said that an order was given to treat Resident #2's elevated heart rate, by another doctor. NP A said he was never asked what to do about Resident #2's incomplete dialysis and was under the impression the dialysis doctor/nephrologist should have made the decision of what to do if a resident did not receive dialysis. NP A said he would not speculate on if Resident #2 could or would have been sent to the hospital for dialysis, but he would expect staff to follow all orders regarding residents' treatments, medication, and care. When NP A was asked if he thought Resident #2 not receiving dialysis for four days was a concern or risk to the resident, NP A said he would not speculate about any potential risk to the resident. Attempts to contact and interview Nephrologist on 10/10/2025 at 4:13pm and on 10/11/2025 at 11:33am were unsuccessful. Record review of facility policy titled Dialysis and dated as revised November 2013 revealed in part: Dialysis is a process used to remove fluid and waste products from the body when the kidneys are unable to do so because of impaired function or when toxins or poisons must be removed immediately to prevent permanent or life-threatening damage. The purposes of dialysis are to maintain the life and well-being of the patient until kidney function is restored and to remove unwanted substances from the blood if renal function does not return. Methods of therapy include hemodialysis, hemofiltration, and peritoneal dialysis. 13. The medication regimen will be assessed by the physician and the pharmacist. When the resident is dialyzed, drug administration times may need to be changed to coincide with the dialysis schedule to prevent their removal. Medication review will be ongoing. Record review of undated facility policy titled Notifying the Physician of Change in Status, revealed in part: 1. The nurse will notify the physician or their delegated nurse practitioner or physician assistant with change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record. The nurse will document all attempts to contact the physician, all attempts to notify the family and/or legal representative, the physician's response, the physician's orders and the resident's status and response to interventions. If the resident remains in the facility and a significant change has occurred, update the care plan accordingly. This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:14 pm. A plan of removal was requested. The following Plan of Removal (POR) submitted by the facility was accepted on 10/11/2025 at 2:39 p.m. The plan of removal reflected the following: Facility Name: Date: October 11, 2025 IJ Component: F698: Quality of care: Hemodialysis Facility failed to ensure resident #2 received hemodialysis on 10/3/25. Immediate Actions: SBAR/Change of condition assessment completed on 10/10/25 with notification of provider and responsible party. No new orders were obtained for Resident #2. Hemodialysis was resumed on next scheduled day (10/06/25) with no missed treatments since 10/06/25. Facility Plan to ensure compliance: 1. 100% review of all facility residents receiving dialysis completed by DON, ADON, and Regional Compliance Nurse on 10/10/25 to identify any other residents receiving dialysis treatments. 3 additional residents identified as receiving dialysis services. 2. 100% assessment of all facility residents ordered to receive hemodialysis treatments were audited on 10/10/25 to ensure no other residents missed hemodialysis treatments. One resident identified as unable to fully complete the session on 10/10/25, charge nurse completed SBAR and notification to MD with new monitoring orders obtained. 3. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 10/10/2025 regarding a. Change of Condition: When to Report to MD/NP/PA and follow-up communication b. Abuse/Neglect c. Dialysis: Facility's dialysis policy in-serviced for enforcement. (No revision of policy needed as policy is effective but was not being followed). 4. DON/ADON will in-service facility staff by phone and/or in person starting 10/10/2025 regarding facility policy on Abuse/Neglect. Goal for completion of this education to be completed by end of day on 10/11/25. Facility staff, including PRN staff, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/10/25 regarding Change of Condition to include when to Report to MD/NP/PA. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 6. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 10/10/25 regarding facility's dialysis policy. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 7. Nurses (LVN/RNs) will utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). 8. The Medical Director was notified by Administrator on 10/10/25 at 8:50pm regarding the immediate jeopardy citation. 10. An Ad-hoc QAPI meeting was held on 10/10/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will monitor changes of condition x 4 weeks to ensure changes of condition have been reported to the MD and followed up. DON/Designee will monitor Dialysis residents x 4 weeks to ensure that residents did not miss any dialysis or had any incomplete dialysis session, if dialysis sessions were missed or incomplete that an SBAR was completed, and was the resident monitored. The Plan of Removal was confirmed for the IJ by monitoring from 10/12/2025 through 10/16/2025 as follows: On 10/10/2025 at 7:30 p.m., request was made with the Administrator and DON to review the dialysis communication sheet, progress note and SBAR for Resident #2 regarding her missed dialysis treatment on 10/03/2025. In an interview on 10/12/2025 with licensed nurses who worked 6:00am-2:00pm, at 2:03 p.m., Treatment Nurse A, ADON A, LVN A, LVN B, LVN C, LVN D, LVN E, LVN G, and RN B who were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate numerous examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. They were all able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/12/25 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the audits as there was no updated information to review for F798 related to Dialysis residents from Friday because their POR only indicated audits would be conducted Monday through Friday. In an interview on 10/13/2025 at 3:18 pm with licensed nurses who worked the 2:00pm-10:00pm shift, who were all knowledgeable of the step-by-step process using the SBAR as a communication tool and the facility's dialysis policy and when and how to utilize the skilled nurse's notes, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). RN B, Treatment Nurse and ADON A said they were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate various examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. In an interview on 10/13/2025 at 4:00 PM the Medical Director said that she was notified about the IJ being called, and she had been included on the POR. She said that all treatments and care should have orders, should be documented, and standard. The Medical Director said that all residents who receive dialysis should have orders, and the orders should be followed. She said that the physician should be notified if or when a resident did not receive hemodialysis as ordered. On 10/13/25 at 5:07pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. Resident #2's dialysis sheet was incorrect. In an interview on 10/14/2025 at 2:13 pm with MDS Coordinator, who said that she worked full time Monday through Friday on the day shift. She said she was able to articulate the step-to-step process for using the SBAR as a communication tool. She gave multiple examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. She was able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/14/25 at 6:56 pm a request was made with the Administrator, DON, Corporate and Regional staff requested staff list, wound care list and medication orders status post wound care doctor, no MAR to support pain medication audits. Still pending facility audit of Resident #2's transfer to the hospital on [DATE]. Dialysis and other documentation remained incomplete. In an interview on 10/15/2025 at 6pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for using the SBAR as a communication tool. She gave multiple examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. She gave multiple examples of neglect that included isolating a resident or not changing or feeding them. She was able to explain what a change in condition was and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. She was able to articulate the facility's dialysis policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). The Administrator was informed that the immediacy was removed on 10/16/2025 at 7:43 p.m. The facility remained out of compliance at a scope of pattern at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #2) - The facility failed to administer Resident#2's IV antibiotic as ordered from her admission on [DATE]-[DATE]. An immediate Jeopardy (IJ) was identified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:11 pm. While the Immediacy was removed on 10/19/2025 at 5:44 pm, the facility remained out of compliance scoped at pattern with no actual harm and potential for more than minimal harm due to the facility's need to complete in-service training and evaluate the effectiveness of their corrective systems. This failure had the potential to place residents at risk for delayed treatment, and worsening infections which can lead to actual harm. Resident #2 was admitted to the hospital with critically elevated white blood cell count, sepsis and had an above the knee amputation of both of her legs. Findings Included: Resident #2 Record review of Resident #2's admission Record dated 10/22/25 revealed she was a [AGE] year old female who admitted to the facility on [DATE] from another state with diagnoses that included: cerebral infarction (a condition that occurs when blood flow to the brain is interrupted, causing brain cells to die), sepsis due to Escherichia Coli (a life-threatening infection, where bacteria from the intestine spreads to the blood stream and triggers a systemic inflammatory response in the body), severe sepsis with septic shock (an infection that leads to life threatening organ dysfunction and failure), pressure ulcer of sacral region (a skin and soft tissue injury that develops over the sacrum (the bone at the base of the spine) due to prolonged pressure, friction or shear which causes the tissue to breakdown and form an open wound), dependence on renal dialysis (a lifelong, and life sustaining therapy involving regular treatments that perform the function of the kidneys to filter waste and remove excess fluid from the blood for people with severe or permanent kidney failure), and gastrostomy status (an opening in the abdomen with insertion of a tube directly into the stomach that allows for nutrition, medication and fluids to be administered to a person unable to eat or drink anything by mouth). Record review of Resident #2's admission Minimum Data Set (MDS) dated [DATE] revealed she had a SAMS (Staff Assessment for Mental Status) completed and was coded as being severely impaired in cognitive skills for daily living decision making. Resident #2 was also coded as having upper and lower extremity impairments on one side of her body and was totally dependent on at least one staff member to provide all ADL (Activities of Daily Living) care. Continued record review revealed Resident #2 was coded in Section M related to Skin Conditions as having two stage four pressure ulcers upon admission. Six unstageable wounds upon admission, and five venous or arterial ulcers. Resident #2 was also coded under Section M as having an infection of the foot. In Section N of the MDS for Medications she was coded as having received antibiotics within the last 7 days. Record review of Resident #2's comprehensive care plan review with a review completed date of 10/06/2025 revealed in part: Focus.Resident #2 is on antibiotic therapy r/t sepsis, r/t wounds, UTI and aspiration PNA.Goal.The resident will be free of any discomfort or adverse side effects of antibiotic therapy through the review date. Target Date: 10/12/2025.Interventions.Administer medications as ordered. Record review of Resident #2's out of state hospital records dated 09/29/2025 revealed she had the following order: Piperacillin Tazobactam (Zosyn) 4.5 g in Sodium Chloride 0.9% 100 ml IVPB Dose: 4.5 g.Freq: every 12 hours.Route: IV.Indications of use: Cellulitis. Record review of Resident #2's physician order dated 9/30/25 at 7:15 pm revealed the following order: Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 100 gram intravenous every 12 hours for wound infection for 14 days, and was confirmed by LVN B. Record review of Resident #2's MAR dated September 1, 2025, through September 30, 2025, revealed Resident #2 did not receive Piperacillin Sod-Tazobactam So Intravenous Solution Reconstituted 4.5 (4-0.5) GM (Piperacillin Sodium Tazobactam Sodium) Use 100 gram intravenous every 12 hours for wound infection for 14 days, as ordered. Continued record review revealed Resident #2 did not receive the medication on 9/30/25 and the order was discontinued on 10/01/25. Record review of Resident #2's Medication Administration Record (MAR) dated October 1, 2025, through October 31,2025 revealed the following: Zosyn Intravenous solution 4-0.5 GM/100 ML Piperacillin Sodium-Tazobactam Sodium in Dextrose (sugar water) Use 100 ml intravenously every 12 hours for Sepsis r/t E. Coli Continue until 10/16/2025.D/C Date: 10/04/2025 at 5:25pm. There was no administration of the medication documented on 10/01/25 for the 06:00 am dose or the 5:00pm dose. There was no documentation on 10/02/25 for the 06:00am dose and the 9=other/see nurse notes. was documented by RN A for the 5:00pm dose. Continued record review revealed no corresponding nurse notes. Record review of Resident #2's progress notes revealed Resident #2 had no IV access for antibiotic to be administered as ordered. Record review of ADON A's note dated 10/3/25 at 9:56 am revealed in part, Spoke with Hemodialysis Nurse this am.OK received to insert midline (a type of long IV catheter inserted into a large vein in the upper arm and is the middle ground between a standard peripheral (type of IV catheter inserted into a vein near the surface of the skin) IV and a central line) for IV ABT therapy. Continued record review of ADON A note dated 10/3/25 at 10:32 am Consent received from RP to insert midline for ABT use. Call placed to IV Company for insertion. Record review of Resident #2's progress notes dated 10/04/25 revealed LVN C documented the following: Note Text: Called Pharmacy A regarding Zosyn IV 4.5 gm which wrong dose (3.375gm) was dispensed to facility and altered dosage in resident's order by pharmacy; spoke with pharmacist on call who apologized for their mistake and confirmed the current dose of Zosyn 4.5 gm is no available in facility's pyxis to be administered. Medical Director notified, new order to administer Zosyn 3.375 gm IV every 8 hours until pharmacy delivers Zosyn 4.5gm and stop date changed to 10/19/25. Called Pharmacy A and Pharmacist notified. Record review of Resident #2's MAR dated October 1, 2025, through October 31,2025 revealed, Zosyn Intravenous Solution 3- 0.375 GM/50ML (Piperacillin Sodium-Tazobactam Sodium in Dextrose) Use 3.375 gram intravenously three times a day related to URINARY TRACT INFECTION, SITE NOT SPECIFIED. administer every 8 hours until Zosyn 4.5gm delivered from pharmacy, was documented as administered to Resident #2 by LVN C on 10/04/25 at 8:00pm. Record review of Resident #2's MAR dated October 1, 2025, through October 31,2025 revealed her admission order for Zosyn Intravenous Solution 4-0.5 GM/100ML (Piperacillin Sodium Tazobactam Sodium in Dextrose) Use 100 ml intravenously every 12 hours for SEPSIS R/T E. COLI until 10/19/2025 was documented as administered to Resident #2 on 10/05/25 at 5 pm, by RN A. Observation on 10/09/2025 of Resident #2's wound care treatment at 10:57 am performed by ADON A and assisted by CNA A. ADON A was asked prior to the start of Resident #2's treatment if Resident #2 had been medicated for pain and ADON A said Resident #2 had been medicated 30-40 minutes earlier. Observation of Resident #2 who was dressed in a clean facility gown and had just been showered and transferred back into her bed. None of the wounds were covered with any dressings as they had been removed or became dislodged during the shower. Resident #2 was nonverbal and did not respond with hand gestures as both of her hands and arms were contracted. She was awake and alert with her eyes open and her facial expression appeared calm and relaxed. Enhanced Barrier and Universal Precautions were maintained throughout the procedure and staff donned and doffed PPE appropriately, before, during and after the procedure. Resident #2's privacy was maintained throughout the wound care procedure. The wound care treatments began with Resident #2's sacrum which had no dressing post shower. The sacral wound was shaped like a large kidney bean. The surface area of the wound was large; she had wounds on both her right and left buttock's that appeared to have merged or blended into one giant wound with a thin strip of skin separating each buttock cheek and appeared tethered from the base of her back through her anus. The right buttock surface area appeared to be approximately 12 x 2 X 4, and the left buttock surface area appeared to be 15 X 4 X 4. The right buttock was a red beefy color with brown edges. It was leaking a copious amount of serosanguinous fluid after ADON A cleansed the area per treatment orders. There was some active bleeding of bright red blood as ADON A continued with the treatment as ordered and Resident #2 appeared to have no facial or physical response during the treatments to her bilateral buttocks. The left buttock had the same amount of serosanguinous leakage of fluid and brown edges of the perimeter of the wound. The wound bed was paler pink, with no active bleeding observed at that time. ADON A completed the treatments to Resident #2's bilateral buttock area. Resident #2's bilateral lower legs appeared emaciated and thin. Her right lateral leg just above her ankle appeared to be exposed to the tendon, and her right heel appeared black. Her right ankle was a black circle where her ankle was located. Resident #2's first, second and third toes of her right foot were completely black and appeared shriveled and fragile. Resident #2's right lateral foot was also black. Resident #2's Left lateral ankle was black and her left heel had an open ulcer that was approximately 4X2 in size. The second toe of her left foot was completely black, shriveled and appeared fragile. Resident #2 tolerated the wound care treatments without any visible, verbal, or audible reaction until ADON A painted betadine on her left lateral ankle which was the last treatment. Resident #2 could be heard inhaling deeply with her eyes closed. Resident #2 had her eyes closed throughout the treatment but had been breathing calmly and quietly up until that point. ADON A spoke calmly to her and reassured her she was done with the treatment. Resident #2 briefly opened her eyes and then closed them again, resuming her calm breathing and appeared to be in no apparent distress. In a telephone interview on 10/09/25 at 2:46 pm with the admitting nurse LVN A, she said she reviewed the hospital records of Resident #2 on 09/30/2025 to have orders to treat her wounds and infection. She said that she clarified the admission orders with NP A, entered the orders, and enlisted the help of other staff on duty to help enter the admission orders, but she failed to ensure that all the orders were entered before her shift ended. She said that Resident #2 was admitted with a wound infection, and was prescribed IV Zosyn to treat the infection, she called to clarify with NP A an order to administer the Zosyn through her pre-existing hemodialysis site, and NP A said that he would address the issue when he rounded on 10/01/2025. In a telephone interview on 10/09/2025 at 4:46 pm with Medical Director who was also the attending physician for Resident #2. The Medical Director said that she was not notified of any issues or concerns with Resident #2 receiving the IV antibiotic Zosyn as ordered. The Medical Director said she would not speculate what potential impact could result from Resident #2 not receiving the antibiotic as prescribed from her admission on [DATE] until the evening of 10/04/2025. The Medical Director said she would expect staff to follow physician orders and to notify them if or when there were any changes or issues. Interview with Hemodialysis Nurse on 10/10/2025 at 9:38 am who said she was familiar with Resident #2. Hemodialysis Nurse said that she had been contacted by facility nurse regarding a midline IV insertion for the resident but could not recall the date. Hemodialysis Nurse said Resident #2 admitted to the facility with a central line dialysis access port to her right chest and sometimes a facility will ask the Nephrologist if medications like antibiotics could be administered during dialysis through the dialysis port. The Hemodialysis Nurse said she was not asked to administer any antibiotic for Resident #2 through her dialysis port and was not aware that Resident #2 did not receive her antibiotics as ordered from her admission on 0 9/30/2025 until 10/04/2025. The Hemodialysis Nurse said that Resident #2 should have received her antibiotic as ordered because any infection she may have had could have gotten worse. Interview with the DON on 10/10/2025 at 10:18 am who said the admitting nurse should identify any skin issues at the time of admission, obtain orders from the primary physician for all medications and wound care and notify the acting wound care nurse to complete a second skin assessment within 24 hours. She said that there should be a clinical review of all new admissions on the next business day to ensure the accuracy of the admission process, that orders were entered and implemented, and she did not remember if there was a clinical review on 10/01/2025 for Resident #2. She said that there should be a clinical review each business day to address any new concerns or changes in conditions. The DON said that in the clinical review 24-hour reports, and direct care staff provide reports in the morning clinical stand-up meetings to help ensure continuity of resident care because they discuss medication orders, any obstacles, or delays in getting medications or orders. They discuss treatments that would include wound care and or hemodialysis treatments, to ensure residents with these orders receive the proper medications and treatments. She said that she was not aware that there were any concerns with Resident #2's wound care, IV antibiotics or dialysis and that the nurse at the time would be responsible for notifying the MD if Resident #2's IV antibiotic medication needed clarification of the strength or if the incorrect dose was delivered or if the resident had no other IV access except the dialysis port. The DON said the nurse at the time would be responsible for notifying the MD if Resident #2 had not completed hemodialysis so that the physician could give an intervention. The DON said she was not sure why that had not been done for Resident #2. The DON said she could not recall if she reviewed Resident #2's clinical records prior to her facility admission or facility electronic clinical records since admission. The DON said that she had not completed a physical assessment of Resident #2 since her admission on [DATE]. Interview at 10:25 am on 10/10/25 with NP B who said he had been out of town when Resident #2 admitted to the facility and NP A was covering for him and had seen Resident #2 the day after her admission on [DATE]. NP B said that Resident #2 was admitted with multiple wounds and was already being treated with IV antibiotics in the hospital and was positive for urine and wound with the same organism E. Coli. NP B said he was unaware of Resident #2 not receiving IV Abt Zosyn as ordered and would not speak to why it was or was not started from admission on [DATE]. NP B said today was the first day he saw Resident #2 and his expectation was that if a resident discharged from a hospital on medications, those medications would be continued as ordered. When asked what could happen if a resident were supposed to be on antibiotics and did not get them as ordered, NP B said the infection could get worse and he received an emergency text from the Medical Director this morning to see Resident #2. In a telephone interview on 10/10/2025 at 11:33am with NP A, he said that he was contacted at the time of Resident #2's admission, he reviewed medications and treatments for wounds with the admitting nurse, and he gave order to continue with treatment and medication orders from the hospital medical records. He said that he rounded with Resident #2 on 10/01/2025, she was prescribed Zosyn a broad-spectrum treatment for an E. Coli infection of her urinary tract, wounds, and pneumonia. He said that he was asked to clarify the order for Zosyn with the pharmacy, and he was under the impression that the medication would be delivered and administered the same day. He said that if he had been informed, he would have decided on a different treatment plan. He said that he would not speak on risk to residents, or if Resident #2 should have been sent to the hospital. He said that his expectation is that staff enter orders from the time of admission, follow orders, and make notifications to a physician when medications are not available, treatments are missing, and when there is a change in condition. Telephone interview with Wound Care Doctor A on 10/10/2025 at 5:33pm who said he had not been notified prior to 10/02/2025 of Resident #2's admission or need for a wound consultation. Wound Care Doctor A said the first time he examined/assessed Resident #2 was on 10/02/2025 and from what he could remember, she admitted with multiple extensive wounds, including her sacrum and buttocks and her toes were at risk of auto (self) amputation. Wound Care Doctor A said he did not know that the orders he wrote for recommended treatments for Resident #2 had not been implemented by facility staff until 10/04/2025. Wound Care Doctor A said that while he did not see or notice any indication of infection of Resident #2's wounds while he provided care, orders for treatments and any antibiotics should be followed. Wound Care Doctor A said he was not aware that Resident #2 had not received her IV antibiotic as ordered from admission. Record review of policy titled, Medication Administration and General Guidelines, with a date of 2025 read in part, Policy Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication, monograph of all medications is available in LinkRx otherwise authorized personnel should refer to Drug Reference material provided by facility. Procedure. 2. Medications are administered in accordance with written orders of the attending physician. 6. All current medications and dosage schedules, except topicals used for treatments, are listed on the resident's medication administration record (MAR). This was determined to be an Immediate Jeopardy (IJ) on 10/10/2025. The Administrator was notified on 10/10/2025. The IJ template was provided to the facility on [DATE] at 8:14pm. A plan of removal was requested. The following Plan of Removal (POR) submitted by the facility was accepted on 10/11/2025 at 2:27 p.m. PLAN OF REMOVAL Name of Facility: Date: October 11, 2025 IJ Component: F760: Significant Medication Errors Facility failed to administer Resident #2's IV antibiotic as ordered to treat UTI, wound sepsis, and Pneumonia from admission 9/30/25-10/5/25. Immediate Actions: SBAR/Change of condition assessment completed on 10/10/25 with notification of provider and responsible party regarding the missed IV antibiotics. Correct dosage of IV antibiotics have been obtained by facility and are being administered as ordered. Facility Plan to ensure compliance: 1. 100% audit completed of facility residents completed on 10/10/25 to identify any residents with IV antibiotics No additional residents identified as receiving IV antibiotics. 2. 100% audit completed on 10/10/25 of facility residents to identify any missed medications and/or treatments. Providers for residents identified as missing medications/treatments were notified and medication error documentation completed on 9 facility residents identified as missing medications/treatments. 3. Regional Compliance Nurse provided in-service to DON, ADON, and Administrator on 10/10/2025 regarding: a. admission Process to include reconciling treatment and medication orders. b. Medication Administration policy in-serviced for enforcement (no revision of policy required, as policy is effective but not being followed). 4. DON/ADON will in-service facility staff by phone and/or in person starting 10/10/2025 regarding facility policy on Abuse/Neglect. Goal for completion of this education to be completed by end of day on 10/11/25. Facility staff, including PRN staff, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 5. DON/ADON will in-service nurses (LVN/RNs) by phone and/or in person starting 10/10/25 regarding the admission Process to include reconciling treatment orders and medication orders. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 6. DON/ADON will in-service nurses (LVN/RN) by phone and/or in person starting 10/10/25 regarding Medication Administration. Goal for completion of this education to be completed by end of day on 10/11/25. All nurses (LVN/RNs), including PRN nurses, not in serviced by 10/11/25 will not be allowed to provide resident care until training has been completed. 8. The Medical Director was notified by Administrator on 10/10/25 at 8:50pm regarding the immediate jeopardy citation. 9. An Ad-hoc QAPI meeting was held on 10/10/25 by the interdisciplinary team to discuss the immediate jeopardies and review the plan of removal. Monitoring: DON/Designee will monitor admission Process daily, Mon-Fri, x 4 weeks to ensure any new admissions and readmissions had reconciled treatment and medication orders. Nursing administration designee will complete admission checklist audit to ensure medication reconciliation has been double checked from what was ordered versus what the facility staff enters into (EMR) the facility's electronic record. DON/Designee will monitor Medication & Treatment Administration Records daily, Mon-Fri x 4 weeks to ensure all medications & treatments were signed out, administered, and available by utilizing the Missed Med Report during morning clinical meeting. The Plan of Removal was confirmed for the IJ by monitoring from 10/11/2025 through 10/19/2025 as follows: Interview on 10/10/2025 at 4:00 p.m. with the Medical Director, who said that she was notified about the IJ being called, and she had been included on the POR. In an interview on 10/12/2025 with licensed nurses who worked 6:00am-2:00pm, at 2:03 p.m., Treatment Nurse A, ADON A, LVN A, LVN B, LVN C, LVN D, LVN E, LVN G, and RN B who were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate numerous examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. They were all able to articulate the facility's admission Process to include reconciling treatment orders and medication orders. policy and when and how to utilize the skilled nurse's notes, SBAR, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). On 10/12/2025 at 5:24 pm a request was made with Administrator, DON, Corporate and Regional staff to review the audits as there was no updated information to review F760 related to medications because their POR only indicated audits would be conducted Monday through Friday. Record review of Resident #2's progress note dated 10/13/2025 at 12:33pm and completed by ADON A read in part, 12:30-Call received from Lab with critical lab value of WBC @21.1. 12:31-Call placed to NP B and informed at this time of results. NP B stated he would call back. Waiting for return call. Record Review of Resident #2's SBAR and Transfer Summary dated 10/13/2025 and completed by ADON A, did not have details as to what the change in condition was or why Resident #2 was being transferred. Interviews on 10/13/2025 with licensed nurses at 3:18pm who worked the 2:00 pm-10:00 pm shift, who were all knowledgeable of the step-by-step process using the SBAR as a communication tool and were all able to articulate the facility's admission Process to include reconciling treatment orders and medication orders, dialysis policy and when and how to utilize the skilled nurse's notes, and/or other routine follow-up documentation to document the change in condition related to missed hemodialysis treatments and other changes in condition in the facility's electronic medical record (EMR). LVN A, LVN C and LVN G said they were all knowledgeable regarding facility policy on Abuse/Neglect. They were all able to articulate various examples of ANE including physical, sexual, verbal, emotional and misappropriation of property. They all gave multiple examples of neglect that included isolating a resident or not changing or feeding them. They were all able to explain what a change in condition and the facility policy and procedure on identifying changes in condition and proper notification of changes in condition to physicians and resident responsible parties. In an interview on 10/13/2025 at 4:00 pm the Medical Director said that she was notified about the IJ being called, and she had been included in the POR. She said that all treatments and care should have orders, should be documented, should be followed as ordered and should be standard. The Medical Director said that any resident who received hemodialysis should receive the treatments as ordered and the physician should be notified if and when a treatment or order cannot be followed so they can prescribe an alternative treatment order or intervention. On 10/13/2025 at 5:07 pm a request was made with the Administrator, DON, Corporate and Regional staff to review the records for Resident #2 and provide details about her SBAR and transfer to hospital. Resident #2's dialysis sheet was incorrect. In an interview on 10/15/2025 at 9:40am with an Attending Physician at a local hospital, she said Resident #2 was admitted with a chief complaint of elevated WBC, diagnosed with sepsis, and was treated with the IV antibiotic Vancomycin. She said that there was blood culture pending to establish the cause of the infection. She said that Resident #2 admitted with extensive wounds. She said that Resident #2's wounds to her feet were necrotic with no blood flow, and has been recommended for bilateral AKA. She said that they will continue to monitor after the surgery for signs of infection because it is possible the infection has spread to the bone. She said that Resident #2 was nonverbal and not able to express if she was in pain, but she did respond to stimuli with facial cues. She said that Resident #2 had PRN morphine to manage her pain. She said that in the absence of antibiotics or wound care her infection and wounds could worsen. She said that Resident #2 needed regularly scheduled dialysis, and a physician should be consulted regarding any missed treatment to decide on an alternate treatment plan. In an interview on 10/15/2025 at 6:00 pm with RN A who said she worked at the facility fulltime and usually on the 10pm to 6am shift but would sometimes pick up extra shifts or different shifts prn. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, to stop the treatment or procedure, redo the assessment and check for any other orders for interventions and if interventions were ineffective, she would initiate SBAR for pain and notify the MD and RP for the resident. In an interview on 10/16/2025 during the 6:00am-2:00pm shift with the Assistant Business Manager at 11:05am and Human Resources Director at 11:05am, both acknowledged being trained on abuse and neglected, provided types of abuse and neglect, reporting concerns with abuse and neglect to the Administrator who was the Abuse Coordinator immediately. In an interview on 10/16/2025 at 6:01pm with LVN C, she stated she has been employed at the facility since June or July of 2025. She stated she works the 10pm-6am shift on weekends. She stated her last in-service on abuse and neglect was that morning. She stated they went over skin, abuse, neglect, pain, weekly skin assessments, MARs and admission process including all documentation. She stated she knew the different types of abuse and was knowledgeable about the different types of abuse. She stated that abuse was reported to the facility Administrator who was also the Abuse Coordinator. She stated that when working with a dialysis resident, they would complete a dialysis communication sheet before and after the dialysis treatment. LVN C said the residents would be assessed for pain, and vital signs would be checked to ensure they were normal. She was able to articulate the step-to-step process for pain management during care and procedures and reporting uncontrolled pain to the provider using the SBAR as a communication tool. She gave examples of non-verbal signs/symptoms or cues for pain could be crying, breathing heavy, flinching and that she should evaluate any pain signs or symptoms prior to, during and after a procedure or treatment. She said if a resident were exhibiting signs and symptoms of pain, she would stop the treatment or procedure, redo the assessment and check for any other orders or interventions and if interventions were ineffective, she would initiate an SBAR for pain and notify the MD and RP for the resident. LVN C stated if a resident were on dialysis, she would complete the required dialysis communication sheets before and after dialysis and notify the physician, as appropriate regarding any changes in the resident's condition. She stated once a resident had a change in condition, they were to do the change in condition-SBAR, call the physician, call the family and call the DON to notify them of the change in condition and follow the physician orders. She stated she thought the physicians came to see the residents weekly. She stated when working with any resident that was refusing care, the physician, DON, and family would be notified, and physicians' orders would be followed, and she would ensure it had all been documented. LVN C said that the physician and RP also need to be notified if a resident did not receive any medication/s so new or different orders could be implemented. In an interview on 10/16/2025 at 6:13pm with RN J, she stated she has been employed at the facility for 10 years. She stated that she worked the 10pm-6am shift. She stated her last in-service was last night for abuse and neglect. She stated they also reviewed pain and abuse and neglect, and she was knowledgeable about the different types of abuse. She stated abuse was reported to the Administrator/Abuse Coordinator. She stated she was in-serviced on the dialysis process, and that when working with a dialysis resident, she ensured the resident was clean and dry and ensured that they were stable, which included assessing their vital signs. She sta

Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. Based on observation, interviews, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for physical environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. The facility failed to ensure construction-renovations were completed in Hall 400 resulting in 2 residents (Resident #11 and Resident #22) not getting wound care, unpleasant and uncomfortable environment for the residents. The facility failed to keep the dining room door closed by propping it open with a zip tie. These failures could place residents at risk of living in an unsafe, uncomfortable environment and decreased quality of life. The findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for roll left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #21's care plan dated 09/17/25 revealed the following in part: Focus: I am Non-Complaint daily to care and refuse care (Peri-care-wound care-ADL Care) has a preference to not wear briefs, refuses nail care, shaving, haircut, showers, and grooming and wound care.Goal: Prevent New Wounds and Heal Current Wounds- I will be free of Pain or Discomfort Focus: The resident has a behavior problem refusing medications, wound care, ADL care, grooming, no sheet on bed and meals Goal: The resident will have fever episodes of refusing medications by review date Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for roll left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #31's care plan dated 09/19/25 revealed the following in part: Focus: Resident #31 is resistive to care relate to refusing incontinent care, wound treatment, weight and height management, refuses to bathe, shaving, haircuts, nail care, grooming, refuse to allow mid-line to be flushed. Goal: The resident will minimize refusal with care through next review date. Record review of Resident #11's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Native Arteries of Extremities with Gangrene, Right Leg (Severe plaque buildup in the arteries of the right leg, blocking blood flow to the point where tissue has died), Peripheral Vascular Disease( a circular disorder where narrowed, blacked, or spasming blood vessels outside the heart and brain reduce blood flow to the limbs and organs), Atherosclerosis of native arteries of right leg with ulceration of other part of foot (refers to a serious condition where atherosclerosis, the build-up of plaque in the arteries, has severely narrowed the arteries of the right leg, leading to gangrene (tissue death) and ulceration (an open sore) on the foot), non-pressure chronic ulcer of other part of right food with fat layer exposed (a non-healing open sore on the right foot that has penetrated through the skin to the subcutaneous fat layer, but was not caused by external pressure) Hypothyroidism (an underactive thyroid condition where the gland does not produce enough thyroid hormones, causing many of the body's function to slow down), and Hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood). Record review of the Resident #11's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, roll left and right, sit to lying, and lying to sitting on side of bed. Resident #11 requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer. Record review of Resident #11's care plan dated 09/30/25 revealed the following in part:Focus: Resident #11 has arterial ulcer related to Peripheral Arterial DiseaseRelated to third toe status post amputation secondary to gangrene. Goal: Resident #11 will be free from infection or complications related to arterial ulcer through review date. Record review of Resident #11's October 2025 Order Summary revealed an order to Cleanse right third toe arterial ulcer wound with Vashe, pat dry, apply lodosorb Gel to would bed, gauze sponge, cover with gauze border dressing dated 10/11/25. Record review of Resident #11's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. Record review of Resident #22's Electronic Health Record revealed a [AGE] year old male re-admitted to the facility 02/10/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-pressure chronic ulcer of left heel and midfoot with unspecified severity (long standing, non healing wound on the left heel and midfoot that was not caused by pressure), Non-pressure chronic ulcer of other part of left foot with fat layer exposed (A significant wound requiring medical attention, as it is a deeper ulcer that one limited to the skin and suggests damage has reached the subcutaneous tissue), Hereditary sideroblastic anemia (a rare genetic disorder where the body cannot produce sufficient hemoglobin due to a genetic defect) and Encounter for orthopedic aftercare following surgical amputation. Record review of Resident #22's Quarterly MDS revealed a BIMS score of 11, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #22 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. Record review of Resident #22's care plan dated 08/08/25 revealed the following in part:Focus: Resident #22 is at risk for infection related to a site for organism invasion. Goal: Early recognition of infection to allow for prompt treatment.Focus: Resident #22 has a surgical site to LT proximal plantarGoal: Resident's surgical site will show signs of improving and remain free from s/s of infection with treatment as ordered over the next 90 days.Interventions:- Administer supplements as ordered. - Administer treatments as ordered. - Surgeon follow up as needed. Assist Resident/Responsible party with scheduling/transportation as needed. - Wound Doctor Consult. Record review of Resident #22's October 2025 Order Summary revealed an order for Wound Consult dated 10/11/25 and an order for wound care site 6 Post-Surgical Wound Left Heel every day shift for left heel wound dated 10/12/25. Record review of Resident #22's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. In an interview/observation on 10/13/25 at 2:56pm; while walking rounds the back of 400 hallway was observed that had 1 side of the hallway closed off with a closed door and on the other side of the door there was a clear plastic sheet covering the open side of the door. There were no signs posted on the closed door or plastic sheet and signs as to what type of work was being done. There were 3 men on the other side of the door and clear plastic sheet wearing N95 mask or respirator masks and actively spraying the walls and ceilings of the unit. Some residents' doors were closed and the floor was covered with slippery plastic sheeting. All of the residents' doors were covered with plastic sheets that were taped at the top and did not create a complete covering or seal over the entire door and most only partially covered the door with the bottom of at least 8 rooms uncovered and exposed to the sprayed material and dust. The 400 hallway appeared hazy with dust like material floating in the air. There were at least 2 rooms that had EBP signs posted and at least 4 rooms that had residents inside of the rooms. When staff were asked what was happening CNA B and LVN B said she did not know and that administration had not told them anything. Staff said they would like to know as well so they could wear appropriate masks because they did not know what they were breathing or what the residents were breathing. CNA B and LVN B said they had no advanced notice that the work was being done and had no way of notifying residents before the work started. The machine used to spray the cloudy material was extremely loud and sounded like a jackhammer or drill. Interviews and observations with Resident #8, Resident #9 and Resident #11 who were all in their rooms and had EBP signs posted outside their doors. Resident #8 and Resident #9 said they felt ok but were advised they could not leave their rooms while the workers were outside. They said it was loud, but they had no feelings of illness or difficulty breathing at that time. When asked how they felt about being sealed inside their rooms during the work, Resident #8 said he was ok with it and Resident #9 said it was inconvenient. All 3 of the Residents said it was too loud. All of the Residents said no one told them the work would be done that day and no one offered them masks or an option to move or change rooms. In an interview on 10/13/25 at 3:00pm with CNA-AG, she was observed with no mask on. She reported there were about 12-13 residents behind the plastic barrier on hall 400. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. In an interview/observation on 10/13/25 at 3:18pm-Notified Admin, DON and Corporate staff about immediate environmental concerns on 400 hallway and safety of residents who remained on the hallway while the substance was being sprayed. Admin said they had notified residents and family members about the renovations, and she was unsure what the substance was the workers were spraying but she could find out. She said she was unsure if anyone was required to wear any PPE or masks and said that they had signs posted on the front entry regarding the remodeling. The Admin said the facility was undergoing renovations with the new company and it was not construction. She said the workers were painting and had started renovations on 200 hall and were slowly working their way around the building. In an interview on 10/13/25 at 3:56pm with LVN B, she stated there were residents behind the plastic barriers on 400 hall. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. She stated she did not know why the workers were wearing masks. She stated she thought the workers were sanding before painting. She stated that if the workers had masks the residents and staff should have mask as well. She stated there were no residents on oxygen on the 400 hall. She stated there was one resident with COPD. She stated she did not smell any fumes but it was dusty on the hall and it was loud. She stated she was not sure if the residents were asked to move. In an interview on 10/13/25 at 3:59pm with CNA-AG, she stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barriers was needed and she did not know why the mask were needed. She stated she thought the workers were sanding prior painting the hallway. She stated that if the workers had on mask then the residents and staff should have on masks as well. She stated the renovations were loud and she was not sure if the residents were asked to move rooms or not. In an interview on 10/13/25 at 4:04pm with Contractor AO, he stated that he and the workers were spraying texturizer on the ceiling, and they would paint on 10/14/25. He stated that they were wearing the masks because it leaves dust that you should not breath in. In an interview on 10/14/25 at 11:48am with Resident #7, he stated he did not get any notice that the facility was doing any construction in the building. He stated he resides on hall 400. He stated the contractors were scraping, drilling, and painting in the hallway and it was loud. He stated everything had been flying in the air and it was affecting his sinuses, causing him to become congested and he reported he had diarrhea. In an observation on 10/14/25 at 9:38am, the dining room door was open and there was a zip tie propping the door open. There was also an extension cord running from inside of the dining room onto the outside of the dining room. The extension cord was zip tied to the hinges of the door, impeding it from closing. Surveyor attempted to close the door but it would not shut due to the extension cord being zip tied to the hinges of the door. In an interview on 10/14/25 at 9:41am with the Director of Food and Nutrition, he stated the zip tie had been on the door for about 2 months. He stated the facility did not put the tie zips there, he reported the company that had come out for their Air Conditioning had put the zip ties on the door. He stated the zip ties and extension did not stop the doors from closing. In an interview on 10/14/25 at 11:40am with Administrator-A, she stated the extension cord and zip tie was put there by the air conditioning company. She stated she would take it down and plug it somewhere else. In an interview on 10/15/25 at 12:11pm with ADON-M, she stated some of the residents on Hall 400 were not seen by the wound care doctor (Resident #11 and Resident #22). She stated she was not given a reason why the residents were not seen but she stated the wound care doctor reported that she did not want to go behind the barrier of the renovations on the 400 hall. She stated there was a barrier cutting off the hallway where renovations were being completed (painting). She stated Resident #11 and Resident #22 will not be seen until the following week (Mondays is the wound care doctors rounding days). She stated there was a barrier cutting off the hallway where they were painting. In observation rounds on 10/20/25 at 2:13pm on Hall 300, the hall smelled of urine and bowel movement. In an interview on 10/20/25 at 2:14pm with Resident #21 and Resident #31, both residents were observed lying in their beds. Upon entering Resident #21 and Resident #31's room, the smell intensified. The room smelled of urine, bowel movement, and body odor. The surveyor had on a mask but was able to smell the odor through the mask. Resident #21 stated he did not have any concerns with the smell of the room and reported that the room smelled fine. In an interview on 10/20/25 at 2:45pm with Regional Compliance Nurse-R, Regional Compliance Nurse-R was observed entering the room of Resident #21 and Resident #31. He stated the residents room did have an odor and described the smell as body odor, bowel movement and body fluid. He stated the smell was contributed to the lack of wound care. He stated Resident #21 and Resident #31 refuse wound care and stated it smells sour in the residents room. He stated he was unsure of what had been done by the administrator to address the smell. In an interview on 10/21/25 at 3:31pm with Resident #38, the resident resides on the 300 hall. He stated he did not like the smell of the 300 hall and he described the smell as different, then said it was like poop. He stated he could not smell it in his room but reported he could smell it when he goes in the hallway. He stated he would like for the hallway to smell better, because it smells that way all the time and he is sick of it. He stated this is his home and he would want it to smell better. He stated he has not spoken to anyone regarding his concern for the smell. He stated he felt as if staff knows that it smells and does not care. In an interview on 10/21/25 at 3:34pm with MA-AE, she stated there had always been an odor on the 300 hall and it was resulting from two of the resident in one of the rooms on the 300 hall. She stated the smell emits from the room into the hallway and into some of the other residents room. She stated she did not know what the facility management was doing to address the problem. She stated she did not know if the facility staff had spoken to the other residents about the concern. She stated whatever the facility management was doing about the smell was not effective. In an interview on 10/22/25 at 9:20am with Family Member #40, she stated the facility smelled horrible. She stated she was able to smell it as soon as she turns the corner to walk down hallway 300. She stated the smell hits you in the face. She stated it smelled like urine, sh**, and like something spoiled. She stated she smell was coming from one of the rooms on the 300 hall. She stated she could smell it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. He stated it smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated the staff had not asked him how he felt about the smell and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there is a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one times a day and the rooms of concern are cleaned two times a day. She stated she spray odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents home and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for physical environment and it was not provided prior to exit.

Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment.Based on observation, interview, and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 2 of 4 halls; Hall 300 and Hall 400 reviewed for homelike environment. The facility failed to ensure Hall 300 was free of odors. The facility failed to deodorize Resident #21 and Resident #31's room resulting in foul orders filling the 300 Hallway and other residents rooms on the 300 hall resulting in complaints from other residents and family members. The facility failed to ensure construction-renovations were completed in Hall 400 resulting in 2 residents (Resident #11 and Resident #22) not getting wound care and living in an unpleasant and uncomfortable environment for the residents. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, uncomfortable, and unsafe. The findings included: Record review of Resident #21's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Pressure Ulcer of Sacral Region, Stage 4 (a deep wound with full-thickness tissue loss that has damaged muscle, tendon, or bone), Pressure Ulcer of Left Lower back, stage 3 (a full-thickness skin and tissue loss injury that has damaged the skin and fat layer, creating deep crater, but has not yet exposed muscle, bone, or tendon), Pressure Ulcer of Right hip, Stage 4 (a severe, full thickness wound that extends through the skin and fat to expose underlying muscle, tendon, or bone), Pressure Ulcer of Left Ankle, Unstageable, Pressure Ulcer of other site (full thickness tissue loss, but the depth cannot be determined because it is covered by eschar (dead tissue) or other slough (dead or dying tissue)), Major Depressive Disorder(a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), Generalized Anxiety disorder (a common mental health condition characterized by excessive, persistent, and uncontrollable worry and anxiety about various aspects of life), and Benign Prostatic Hyperplasia without Lower Urinary Tract symptoms ( a condition where the prostate gland enlarges but does not cause any noticeable urinary problems) and Colostomy Status (refers to the condition of having a surgical procedure called colostomy). Record review of the Resident #21's Quarterly MDS revealed a BIMS score of 14, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #21 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #21 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with shower/bathe self, upper body dressing, personal hygiene, sit to lying, and lying to sitting on side of bed. Record review of Resident #21's care plan dated 09/17/25 revealed the following in part: Focus: I am Non-Complaint daily to care and refuse care (Peri-care-wound care-ADL Care) has a preference to not wear briefs, refuses nail care, shaving, haircut, showers, and grooming and wound care.Goal: Prevent New Wounds and Heal Current Wounds- I will be free of Pain or Discomfort Focus: The resident has a behavior problem refusing medications, wound care, ADL care, grooming, no sheet on bed and meals Goal: The resident will have fewer episodes of refusing medications by review date Record review of Resident #31's Electronic Health Record revealed a [AGE] year-old male readmitted to the facility on [DATE] with diagnoses including Unspecified Dementia (a diagnosis used when a person exhibits symptoms of dementia by the specific underlying cause cannot be determined), Local Infection of the skin and subcutaneous tissue (an infection that affects the layers of skin and underlying fat), Chronic Venous Hypertension with Ulcer of Right Lower Extremity (there is high blood pressure in the veins of the right leg, which has caused an open sore (ulcer) to form due to poor circulation), Chronic Venous Hypertension with Ulcer of Left Lower Extremity (high blood pressure in the veins of the left leg has caused a non-healing sore (ulcer) to form due to poor blood flow), Schizophrenia, Unspecified (a diagnostic category used in psychiatry when a person exhibits symptoms of schizophrenia but does not meet the full criteria for any specific subtypes of schizophrenia), Pressure Ulcer of Sacral Region, Stage 4 (a severe form of pressure injury where there is full-thickness tissue loss with exposed bone, muscle, or tendons), Pressure Ulcer of Right Heel, Stage 4 (the most severe type of pressure injury, involving deep-tissue damage with full-thickness tissue loss that exposes muscle, tendon, or bone), and Cognitive Communication Deficit (a communication challenge caused by problems with thinking abilities like attention, memory, and executive function, rather than a language or speech problem). Record review of the Resident #31's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #31 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts or holds trunk or limbs but provides less than half the effort) for rolling left to right. Resident #31 required substantial/maximal assistance (Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, and personal hygiene. Record review of Resident #31's care plan dated 09/19/25 revealed the following in part: Focus: Resident #31 is resistive to care relate to refusing incontinent care, wound treatment, weight and height management, refuses to bathe, shaving, haircuts, nail care, grooming, refuse to allow mid-line to be flushed.[sic] Goal: The resident will minimize refusal with care through next review date. Record review of Resident #11's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Atherosclerosis of Native Arteries of Extremities with Gangrene, Right Leg (Severe plaque buildup in the arteries of the right leg, blocking blood flow to the point where tissue has died), Peripheral Vascular Disease( a circular disorder where narrowed, blacked, or spasming blood vessels outside the heart and brain reduce blood flow to the limbs and organs), Atherosclerosis of native arteries of right leg with ulceration of other part of foot (refers to a serious condition where atherosclerosis, the build-up of plaque in the arteries, has severely narrowed the arteries of the right leg, leading to gangrene (tissue death) and ulceration (an open sore) on the foot), non-pressure chronic ulcer of other part of right food with fat layer exposed (a non-healing open sore on the right foot that has penetrated through the skin to the subcutaneous fat layer, but was not caused by external pressure) Hypothyroidism (an underactive thyroid condition where the gland does not produce enough thyroid hormones, causing many of the body's function to slow down), and Hyperlipidemia (high levels of lipids like cholesterol and triglycerides in the blood). Record review of the Resident #11's Quarterly MDS revealed a BIMS score of 15, which indicates cognitively intact. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with oral hygiene, rolling left and right, sit to lying, and lying to sitting on side of bed. Resident #11 requires partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs and provides less than half the effort) with Toileting hygiene, shower/bathe self, upper body dressing, lower body dressing, putting on/taking off footwear, personal hygiene, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, car transfer. Record review of Resident #11's care plan dated 09/30/25 revealed the following in part:Focus: Resident #11 has arterial ulcer related to Peripheral Arterial DiseaseRelated to third toe status post amputation secondary to gangrene. Goal: Resident #11 will be free from infection or complications related to arterial ulcer through review date. Record review of Resident #11's October 2025 Order Summary revealed an order to Cleanse right third toe arterial ulcer wound with Vashe, pat dry, apply lodosorb Gel to would bed, gauze sponge, cover with gauze border dressing dated 10/11/25. Record review of Resident #11's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. Record review of Resident #22's Electronic Health Record revealed a [AGE] year old male re-admitted to the facility 02/10/25 with diagnoses including Type 2 Diabetes Mellitus with Foot Ulcer, Non-pressure chronic ulcer of left heel and midfoot with unspecified severity (long standing, non healing wound on the left heel and midfoot that was not caused by pressure), Non-pressure chronic ulcer of other part of left foot with fat layer exposed (A significant wound requiring medical attention, as it is a deeper ulcer that one limited to the skin and suggests damage has reached the subcutaneous tissue), Hereditary sideroblastic anemia (a rare genetic disorder where the body cannot produce sufficient hemoglobin due to a genetic defect) and Encounter for orthopedic aftercare following surgical amputation. Record review of Resident #22's Quarterly MDS revealed a BIMS score of 11, which indicates moderately impaired cognition. Section GG of the MDS revealed the resident did use a mobility device (wheelchair) and he required supervision or touching assistance (Helper provides verbal cues and/or ouching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently) with eating and oral hygiene. Resident #22 required partial/moderate assistance (Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort) with toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed-to-chair transfer, and tub/shower transfer. Record review of Resident #22's care plan dated 08/08/25 revealed the following in part:Focus: Resident #22 is at risk for infection related to a site for organism invasion. Goal: Early recognition of infection to allow for prompt treatment.Focus: Resident #22 has a surgical site to LT proximal plantarGoal: Resident's surgical site will show signs of improving and remain free from s/s of infection with treatment as ordered over the next 90 days.Interventions:- Administer supplements as ordered. - Administer treatments as ordered. - Surgeon follow up as needed. Assist Resident/Responsible party with scheduling/transportation as needed. - Wound Doctor Consult. Record review of Resident #22's October 2025 Order Summary revealed an order for Wound Consult dated 10/11/25 and an order for wound care site 6 Post-Surgical Wound Left Heel every day shift for left heel wound dated 10/12/25. Record review of Resident #22's wound physician progress note dated 10/13/25 revealed: The patient's visit was rescheduled, unable to access room due to construction in the hallway. In an interview/observation on 10/13/25 at 2:56pm; while walking rounds the back of 400 hallway was observed that had 1 side of the hallway closed off with a closed door and on the other side of the door there was a clear plastic sheet covering the open side of the door. There were no signs posted on the closed door or plastic sheet or signs as to what type of work was being done. There were 3 men on the other side of the door and clear plastic sheet wearing N95 mask or respirator masks and actively spraying the walls and ceilings of the unit. Some residents' doors were closed and the floor was covered with slippery plastic sheeting. All of the residents' doors were covered with plastic sheets that were taped at the top and did not create a complete covering or seal over the entire door and most only partially covered the door with the bottom of at least 8 rooms uncovered and exposed to the sprayed material and dust. The 400 hallway appeared hazy with dust like material floating in the air. There were at least 2 rooms that had EBP signs posted and at least 4 rooms that had residents inside of the rooms. When staff were asked what was happening CNA B and LVN B said they did not know and that administration had not told them anything. Staff said they would like to know as well so they could wear appropriate masks because they did not know what they were breathing or what the residents were breathing. CNA B and LVN B said they had no advanced notice that the work was being done and had no way of notifying residents before the work started. The machine used to spray the cloudy material was extremely loud and sounded like a jackhammer or drill. Interviews and observations with Resident #8, Resident #9 and Resident #11 who were all in their rooms and had EBP signs posted outside their doors. Resident #8 and Resident #9 said they felt ok but were advised they could not leave their rooms while the workers were outside. They said it was loud, but they had no feelings of illness or difficulty breathing at that time. When asked how they felt about being sealed inside their rooms during the work, Resident #8 said he was ok with it and Resident #9 said it was inconvenient. All 3 of the Residents said it was too loud. All of the Residents said no one told them the work would be done that day and no one offered them masks or an option to move or change rooms. In an interview on 10/13/25 at 3:00pm with CNA-AG, she was observed with no mask on. She reported there were about 12-13 residents behind the plastic barrier on hall 400. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. In an interview/observation on 10/13/25 at 3:18pm-Notified Admin, DON and Corporate staff about immediate environmental concerns on 400 hallway and safety of residents who remained on the hallway while the substance was being sprayed. Admin said they had notified residents and family members about the renovations, and she was unsure what the substance was the workers were spraying but she could find out. She said she was unsure if anyone was required to wear any PPE or masks and said that they had signs posted on the front entry regarding the remodeling. The Admin said the facility was undergoing renovations with the new company and it was not construction. She said the workers were painting and had started renovations on 200 hall and were slowly working their way around the building. In an interview on 10/13/25 at 3:56pm with LVN B, she stated there were residents behind the plastic barriers on 400 hall. She stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barrier was needed. She stated she did not know why the workers were wearing masks. She stated she thought the workers were sanding before painting. She stated that if the workers had masks the residents and staff should have masks as well. She stated there were no residents on oxygen on the 400 hall. She stated there was one resident with COPD. She stated she did not smell any fumes but it was dusty on the hall and it was loud. She stated she was not sure if the residents were asked to move. In an interview on 10/13/25 at 3:59pm with CNA-AG, she stated she was not told what the workers were doing or what they were spraying. She stated she did not know why the plastic barriers was needed and she did not know why the masks were needed. She stated she thought the workers were sanding prior painting the hallway. She stated that if the workers had on masks then the residents and staff should have on masks as well. She stated the renovations were loud and she was not sure if the residents were asked to move rooms or not. In an interview on 10/13/25 at 4:04pm with Contractor AO, he stated that he and the workers were spraying texturizer on the ceiling, and they would paint on 10/14/25. He stated that they were wearing the masks because it leaves dust that you should not breathe in. In an interview on 10/14/25 at 11:48am with Resident #7, he stated he did not get any notice that the facility was doing any construction in the building. He stated he resides on hall 400. He stated the contractors were scraping, drilling, and painting in the hallway and it was loud. He stated everything had been flying in the air and it was affecting his sinuses, causing him to become congested and he reported he had diarrhea. In an interview on 10/15/25 at 12:11pm with ADON-M, she stated some of the residents on Hall 400 were not seen by the wound care doctor (Resident #11 and Resident #22). She stated she was not given a reason why the residents were not seen but she stated the wound care doctor reported that she did not want to go behind the barrier of the renovations on the 400 hall. She stated there was a barrier cutting off the hallway where renovations were being completed (painting). She stated Resident #11 and Resident #22 will not be seen until the following week (Mondays is the wound care doctors rounding days). She stated there was a barrier cutting off the hallway where they were painting. In observation rounds on 10/20/25 at 2:13pm on Hall 300, the hall smelled of urine and feces. In an interview on 10/20/25 at 2:14pm with Resident #21 and Resident #31, both residents were observed lying in their beds. Upon entering Resident #21 and Resident #31's room, the smell intensified. The room smelled of urine, feces, and body odor. The surveyor had on a mask but was able to smell the odor through the mask. Resident #21 stated he did not have any concerns with the smell of the room and reported that the room smelled fine. In an interview on 10/20/25 at 2:45pm with Regional Compliance Nurse-R, Regional Compliance Nurse-R was observed entering the room of Resident #21 and Resident #31. He stated the residents' room did have an odor and described the smell as body odor, feces and body fluid. He stated the smell was contributed to the lack of wound care. He stated Resident #21 and Resident #31 refuse wound care and stated it smells sour in the residents' room. He stated he was unsure of what had been done by the administrator to address the smell. In an interview on 10/21/25 at 3:31pm with Resident #38, the resident resides on the 300 hall. He stated he did not like the smell of the 300 hall and he described the smell as different then said it was like poop. He stated he could not smell it in his room but reported he could smell it when he goes in the hallway. He stated he would like for the hallway to smell better, because it smells that way all the time and he was sick of it. He stated this was his home and he would want it to smell better. He stated he has not spoken to anyone regarding his concern for the smell. He stated he felt as if staff knows that it smells and does not care. In an interview on 10/21/25 at 3:34pm with MA-AE, she stated there had always been an odor on the 300 hall and it was resulting from two of the residents (Resident #21 and Resident #31) in one of the rooms on the 300 hall. She stated the smell emits from the room into the hallway and into some of the other residents' rooms. She stated she did not know what the facility management was doing to address the problem. She stated she did not know if the facility staff had spoken to the other residents about the concern. She stated whatever the facility management was doing about the smell was not effective. In an interview on 10/22/25 at 9:20am with Family Member #40, she stated the facility smelled horrible. She stated she was able to smell it as soon as she turns the corner to walk down hallway 300. She stated the smell hits you in the face. She stated it smelled like urine, sh**, and like something spoiled. She stated she smell was coming from one of the rooms on the 300 hall. She stated she could smell it down the hall and reported that the smell lingers into Resident #33's room. She stated she had not complained about the smell but reported Resident #33 has complained to corporate about the smell. In an interview on 10/22/25 at 9:25am with Resident #37, the resident resides on the 300 hall. He stated he did not like the way his room or the facility smelled and stated who would like the smell. He stated the smell was worse in the hallway. He stated the smell was coming from one of the rooms on the 300 hall and stated the residents in that room does not allow staff to wash their a**, change their diapers, or tend to their wounds. It smells sh** and rotten flesh. He stated he felt helpless because this was his home and he could not do anything about the smell. He stated if this was his own home it would not have this smell. He stated the staff had not asked him how he felt about the smell, and no one had asked him if he wanted to change halls. In an interview on 10/22/25 at 9:35am with CNA-AJ, she reported there was a concern with odor on Hall 300 because some of the residents refuse care. She stated she could not think of words to describe the smell but it was bad. She stated she did not know what the facility was doing about the smell but reported it has always smelled that way since she started working at the facility, she stated she started working at the facility in November 2024. She stated that this was the residents' home and they have a right to an odor free home. In an interview on 10/22/25 at 9:40am with Housekeeper-AL, she stated she had been employed at the facility for 2 months. She stated there was an issue with odor on the 300 hall. She stated the odor was indescribable and stated it had always smelled bad ever since she started working there and the smell had gotten worse. She stated she was told the source of the smell was from residents refusals of baths and wound care. She stated she cleans each room one time a day and the rooms of concern are cleaned two times a day. She stated she sprays odor neutralizer upon entering and exiting each room and she also sprays the hallways as she exits each room. She stated that she goes through 2-3 bottles of odor neutralizer a week for one hall to try to help the smell but it does not work. She stated the additional cleaning was not helping the odor. She stated that it was the residents' home, and they have the right to have an odor free home. In an interview on 10/22/25 at 10:20am with Resident #33, he did not have any concerns for the smell in his room or in the hallway. In an interview on 10/22/25 at 11:20am with Administrator-A, she stated she does daily observation rounds of the entire facility. She stated she had not observed a pronounced odor to any part of the facility. She stated she had only observed there to be a smell associated with incontinent care and that was normal from residents getting brief changes at every facility. She stated there had not been complaints or grievances about odors in the building. She stated housekeeping does have some targeted rooms that received additional cleaning at the back of 300 hall and 400 hall. Administrator-A sent an email to surveyors with the list of targeted rooms that get additional cleanings, but she reported she did not recall the reason as to why the rooms get additional cleanings. On 10/22/2025 at 1:06pm, a policy was requested for homelike environment, and it was not provided prior to exit.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 out of 1 resident (Resident #2) reviewed for adequate supervision. The facility failed to provide adequate supervision to prevent Resident #2 from eloping from the facility at 2:05 a.m. on 5/6/25 .The noncompliance was identified as Past Non-Compliance. The IJ began on 5/6/25 and ended on 6/6/25 . The facility had corrected the noncompliance before the survey began. The failure placed residents with wander guards at risk of serious harm or death. Findings included:Record review of Resident #2's face sheet dated 7/9/2025, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including Unspecified Dementia (group of symptoms affecting memory, thinking and social abilities), Muscle Wasting and Atrophy (decrease in size), and Other Abnormalities of Gait (a person's manner of walking) and Mobility. Record review of Resident #2's annual MDS dated [DATE], section C revealed a BIMS score of 6 that indicated severe cognitive impairment. Section E revealed Resident #2 had exhibited wandering daily but did not place him at significant risk of getting to a potentially dangerous place or significantly intrude on the privacy or activities of others. Section GG regarding Resident #2's Functional Abilities revealed he needed partial/moderate assistance for oral hygiene, toileting hygiene, showering/bathing, dressing, putting on/taking off footwear and substantial/maximal assistance for personal hygiene. Section V regarding Care Area Assessments revealed Resident #2 was reviewed for risks in the following areas: Cognitive Loss/Dementia (dated 4/11/2025), Communication (dated 4/11/2025), ADL Functional/Rehabilitation Potential (dated 4/11/2025), Urinary Incontinence and Indwelling Catheter (dated 4/11/2025), Behavioral Symptoms with care plan ongoing, Falls (dated 4/11/2025), and Psychotropic Drug Use (dated 4/11/2025). Record review revealed Resident #2 had an Elopement Risk Assessment completed on 2/27/25 that indicated Resident #2 was at risk of elopement. Record review of Resident #2's Care Plan revealed Resident #2 was care planned for being at risk for elopement related to wandering with date of initiation on 4/2/24. Resident #2 was also care planned regarding being noncompliant with wearing the wander guard and removing the wander guard after being applied. Interventions included wander guard with initiation date of 4/2/24with placement and function to be assessed every shift. Interventions added after the incident included Resident #2's family looking at 2 secure facilities due to noncompliance with wander guard with initiation date of 5/6/25 , and 1:1 (continuous observation) close monitoring with initiation date of 5/6/25 . Record review of Resident #2's MAR and TAR for May 2025 revealed from 5/1-5/6/25 that his wander guard was checked every shift with no documentation for night shift of 5/1/25 and sleeping was documented for night shift from 10 p.m. to 6 a.m. of 5/5/25 and 5/6/25 with no specific time documented . Wander guard was checked every four hours from 5/13/25 at 4 p.m. through 5/31/25 at 8 p.m. with no documentation for 5/21/25 at 12 p.m., 5/26 at 12 p.m. and 5/29/25 at 8 p.m. Wander guard was checked every night from 5/14-5/31/25. Safety checks were also documented every 30 minutes from 5/7-5/31/25. Record review of Resident #2's nursing progress note dated 5/6/25 at 12:01 a.m. by LVN B revealed, Resident observed not in bed during rounds. After searching around the unit and the neighborhood without finding resident. Facility management notified hence elopement protocol activated. Resident Responsible party notified. 911 called with police response. Physician also notified.Record review of statement written by CNA G on 5/6/25 revealed CNA G saw Resident #2 between 11:00 p.m. to 11:30 p.m. when CNA G took a snack to Resident #2, and he was asleep in his bed at that time and was not seen during the rest of CNA G's shift. Record review of statement written by LVN B on 5/6/25 revealed during shift report at 10:00 p.m. on 5/5/25 they were advised the door alarm in the Magnolia room (large sitting room) was going off. LVN B stated that about 12 midnight they made rounds on the unit and Resident #2 was not in his bed. LVN B stated that when they made rounds and Resident #2 was not in the center, they checked the Magnolia door, and it showed a green light (the door was operational) , and the door was secured and locked but could not recall the exact time this occurred. LVN B stated they notified CNA G at 12:15 a.m. to help look for Resident #2 and notified the other units to help search as well. Then 1 a.m. after still not being able to find Resident #2, LVN B drove to the nearby streets and neighborhood to search for him. LVN B returned to the facility at 1:45 a.m. and notified the administrator around 2 a.m. that Resident #2 was missing. LVN B notified the local Police Department and Resident #2's Responsible Party at 3:33 a.m.Record review of written statement, RN C revealed on 5/6/25 when they came on duty at 10 p.m. the alarm in the Magnolia room was going off. RN C stated that LVN B came to them at approximately 2 a.m. and told them that Resident #2 was no longer at the facility and then started a search inside and outside the facility. RN C stated the Administrator called them at 2:33 a.m. and had tried to reach LVN B but they were out looking for Resident #2. Record review of written statement, LVN C revealed there was a buzzing sound to the Magnolia door when they arrived for the 10 p.m. to 6 a.m. shift on 5/5/25. LVN C stated they checked the door at approximately 10:30 p.m. and it was secured. LVN C stated that LVN B notified them around midnight that Resident #2 was not at the facility, and they helped with an internal and external search of the facility but was unable to find Resident #2. Record review of written statement dated 5/12/25, CNA H stated they were notified that Resident #2 was missing about 1:30 a.m. but could not recall who notified them. CNA H stated they had gone to the Magnolia area and the door was unsecured. Per interview on 7/9/25 at 5:09 p.m., the Administrator said CNA H was no longer employed by the facility and was terminated for an unrelated offense and was angry. Record review of skin audit dated 5/6/25 but not timed revealed complete head to toe assessment with no wounds noted and vital signs were within normal limits. Record review of the Provider Investigation Report dated 5/12/25 regarding the elopement incident on 5/6/25 with Resident #2 revealed provider response included staff completed an audit of the elopement book for pictures and care plans to assure that all residents who were at risk had been included. Staff checked proper functioning/positioning of all Code Alert bracelets and all functioned as designed. Door checks to be conducted daily to assure proper function. Elopement drills for all three shifts on 5/6-6/7/25. In-services were immediately implemented for resident safety and Code Alerts during power loss and abuse, neglect, prevention of accidents and supervisions of residents. Ad Hoc QAPI was held with the medical director. Record review of facility's Elopement Binder revealed 1:1 logs for Resident #2 from 5/6-6/6/25 when it was documented per the log that Resident #2 was discharged [DATE]. The 1:1 logs showed documentation who was assigned to Resident #2 while he was under continuous monitoring. There was no documentation on the 1:1 logs from 10 p.m. on 5/10/25 to 6 a.m. on 5/11/25, from 2 p.m. on 5/23/25 to 6 a.m. on 5/24/25 (duplicate documentation from 2 p.m. to 6 a.m. noted on 5/23/25), from 2:10 p.m. to 5 p.m. on 5/27/25, from 6 a.m. to 8:30 a.m. on 5/28/25, from 10 p.m. on 5/28/25 to 6 a.m. on 5/29/25, from 2 p.m. to 5 p.m. on 5/30/25, from 10 p.m. on 6/4/25 to 8:30 a.m. on 6/5/25 and 6 a.m. to 7 a.m. on 6/6/25. Record review of facility's Elopement Binder revealed facility's audits for proper function and placement for code alert (wander guard) from 5/14 through 6/27/25, door checks from 4/28/25 through 7/4/25and elopement risk binders from 5/12/25 through 6/20/25 . Record review of facility's Elopement Binder revealed in services for Elopement, Response to Power Off on Exit Doors , Abuse and Neglect with objective staff will check wander guard placement every shift dated 5/6/25. The Elopement in-service included the objection to enhance staff monitoring and supervision by establishing protocols for appropriate staff supervision levels based on residents' risk assessments, encouraging regular observations and interactions. The Elopement in-service also included to implement individualized care plans. The Abuse and Neglect in-service included the objective staff will check wander guard placement every shift. All departments were included in the in-services with 130 staff members in-serviced regarding Elopement, 126 staff members in-serviced regarding Response to Power Off on Exit Doors and 136 staff members in-serviced regarding Abuse and Neglect. Record review of list of residents at risk of elopement provided during the investigation on 7/9/25 revealed there were four current residents at risk of elopement: Resident #3, Resident #4, Resident #5 and Resident #6. During interview on 7/9/25 at 11:06 a.m., LVN B said that they last saw Resident #2 between 11:00 p.m. to 12:00 a.m. and he was in bed and was wearing the wander guard. LVN B said Resident #2 was not in bed when they were making rounds around 12 a.m. but could not remember the exact time of the rounds. LVN B said they notified the administrator after searching inside and outside the facility. LVN B stated one of the doors had the alarm going off when they were searching for Resident #2 so that was when they thought he exited the building. LVN B said Resident #2 was not found before their shift ended at 6 a.m. LVN B said she had in-services regarding elopement that included to check the rooms, check the exit doors, and if the resident was missing then notify the administrator immediately. LVN B said Resident #2 had not tried to exit the facility before during their shift. During interview on 7/9/25 at 11:49 a.m., the Administrator said she was notified at 2:18 a.m. on 5/6/25 by LVN B of the elopement of Resident #2. The Administrator said that the Magnolia door was inspected on 5/6/25 after the incident and no issues were found. The Administrator said that Resident #2 was found by the Activities Director and Business Office after they started searching at 8 a.m. on 5/6/25 in addition to other staff members that were already searching for Resident #2. The Administrator said when Resident #2 was returned to the facility they replaced the wander guard and Resident #2 was placed on 1:1 supervision until he was transferred to the behavioral hospital. The Administrator said that staff should notify the Administrator and DON immediately when they realize a resident cannot be accounted for after performing a search of the facility. The Administrator said that Resident #2 had a history of removing the wander guard but was never exit seeking. The Administrator said that Resident #2 would maneuver off the wander guard. The Administrator said Resident #2 had no injuries or signs of distress when he was found. The Administrator said at the time of the incident on 5/6/25 all cameras were outside the facility and located in the Magnolia area which was the second lobby, one area of the dining room and the porch. During interview on 7/9/25 at 12:24 p.m., the Activities Director said they found Resident #2 around 9 a.m. sitting outside a car/mechanical shop at the intersection of two streets which was around a 25 minute walk from the facility per apple maps directions. The Activities Director said Resident #2 was tired and hungry when they found him but had no obvious injuries and was returned to the facility where an assessment by nursing was performed. On 7/9/25 at 12:52 p.m. all the exit doors to the facility were checked and sounded an alarm when tested. During interview on 7/9/25 at 1:20 p.m., the Administrator said Code Alert was the name for the wander guard they use. The Administrator said she did counsel LVN B who was the nurse involved in the elopement incident of Resident #2. Observation on 7/9/25 at 1:45 p.m. revealed the Administrator showing a video the Administrator stated was Resident #2 exiting the facility from the Magnolia door. An elderly man dressed in red clothing was seen walking away from the facility. The man was seen walking away from the building in the video at time stamp starting at 2:05:56 a.m. on Tuesday 5/6/25. During interview on 7/9/25 at 4:46 p.m., the Senior Maintenance said he checked the Magnolia door the day after the incident with Resident #2. The Senior Maintenance said he checked the wander guard system, keypad and everything locked down normally and everything was functioning as it should. The Senior Maintenance said that there were no prior problems with the door that he was aware of. The Senior Maintenance said the facility had done the life safety survey recently and all doors locked down with wander guard, released keypad and opened within the 15 second regulations. Observation on 7/10/25 at 9:09 a.m. revealed Resident #4's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:11 a.m. revealed Resident #6's wander guard was intact on their left ankle. Observation on 7/10/25 at 9:16 a.m. revealed Resident #3's wander guard was intact on their left leg. Observation on 7/10/25 at 9:19 a.m. revealed Resident #5's wander guard was intact on their right ankle. During interview on 7/10/25 at 1:11 p.m. , CNA I stated the facility was using Code Orange for elopements. CNA I stated elopement procedures included that someone would print the census and check all the halls to make sure everyone was accounted for including to check all the rooms and doors including bathrooms and closets. CNA I said someone would also go around the premises to search. CNA I said also the Administrator and DON should be notified immediately regarding a resident elopement. During interview on 7/10/25 at 11:17 a.m. the Administrator provided documents with information regarding elopements and if residents remove wander guards. The Administrator said if she and the DON were notified that a resident removed the wander guard, they would implement the documents provided . Record review of the documents provided on 7/10/25 at 11:17 a.m. revealed an Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse. During interview on 7/10/25 at 11:55 a.m., LVN D denied any problems with Resident #5 removing her wander guard and said she had worked with Resident #5 since Resident #5 had arrived at the facility which had been over six months. LVN D said the nurses would monitor residents who removed their wander guard and would start a 1:1 with the resident and notify the administrator. LVN D said they had training regarding this information about two months ago in May. LVN D said how they would monitor a resident who was removing their wander guard was that whoever was on a 1:1 with the resident always had eyes on the resident. LVN D said Resident #5 was the only resident with a wander guard she had at this time. During interview on 7/10/25 at 12:00 p.m., the DON said she started at the facility on 5/27/25 so she was not working at the time of the incident of Resident #2's elopement on 5/6/25. The DON said the nurses would monitor residents if they were removing the wander guard and should notify the DON and Administrator. The DON said that they only have four residents currently with wander guards and none of the four current residents with wander guards have behaviors with removing the wander guard. The DON said staff had follow up training regarding wander guards yesterday 7/9/25. During interview on 7/10/25 at 12:00 p.m., the Administrator also agreed none of the four current residents with wander guard have behaviors of removing the wander guard. The Administrator said staff was trained regarding what to do if residents remove wander guards in May.During interview on 7/10/25 at 12:08 p.m., LVN E said he usually works with Resident #3 and Resident #6 and are the only residents at his station with wander guards. LVN E said neither Resident #3 nor Resident #6 tried to remove the wander guard. LVN E said the nurses are who monitor the residents who attempt to remove the wander guards because they are supposed to be checked every shift. LVN E said that the CNAs are supposed to tell the nurses if they see the residents remove the wander guard . LVN E said if the resident was trying to remove the wander guard, then they are to notify the administrator and the DON. LVN E said that they did trainings regarding residents removing the wander guards in May and had an update 7/9/25. LVN E said residents are monitored are through 1:1 observation and this was usually done by a CNA. During interview on 7/10/25 at 12:18 p.m., LVN C said she normally works night shift at the station with Resident #3 and Resident #6. LVN C said that neither Resident #3 nor Resident #6 have problems with trying to remove the wander guards. LVN C said if residents attempted to remove the wander guard, they did 1:1 observation and redirection. LVN C said they checked for placement to make sure the wander guards were functioning correctly and in place. LVN C said that if a resident removes the wander guard, they notify the Administrator and the DON immediately. LVN C said that all staff would participate in monitoring if a resident were removing the wander guard or trying to elope. LVN C said regarding residents removing wander guards they received training a couple a months ago because they had a resident who was removing the wander guards and then a follow up 7/9/25. LVN C said the training included what to do if they hear an alarm, stand at the doors, full census sweep, 1:1 if the resident was known, make sure the wander guard is in place, safety monitoring and notify the DON/Administrator if the residents was continuing to try and exit. LVN C said the priority is the residents' safety. LVN C said she was working the night of 5/5/25 from 10 p.m. to 6 a.m. LVN C said they heard the alarm going off when she was getting report about 10:15-10:20 p.m. LVN C said she went to the Magnolia door with a couple of CNAs and checked the alarm for proper functioning. LVN C said she pushed the door open and the secondary alarm above the door went off. LVN C said she did a census and told the other nurses to do a census at that time. LVN C said that was when the nurse on Station 4 said she could not find her resident, but LVN C said she could not remember what time that occurred. LVN C said then they completed a search and notified the administrator. LVN C said that on the night of 5/5/25 there was a female resident who was sitting by the door who was wearing a wander guard and LVN C said she thought the female resident had touched the door. LVN C said that the female resident was transferred out to a secured unit and was no longer at the facility. LVN C said that after she checked the door the alarm was no longer going off and did not go off the rest of the night. During interview on 7/10/25 at 12:40 p.m., LVN B said she usually works 10 p.m. to 6 a.m. on the #400 hallway. LVN B said Resident #4 is the only resident on her hallway with a wander guard and Resident #4 has never tried to remove the wander guard. LVN B said that if a resident attempted or removed the wander guard , they initiate a 1:1. LVN B said the nurses or CNA would have to be with the resident all the time if they were attempting to remove the wander guard. LVN B said if a resident was removing the wander guard, they would notify the administrator and DON immediately if a resident was placed on a 1:1. LVN B said that they had elopement training and drill about two months ago and then updated 7/9/25. LVN B said that the training included what they are expected to do if the residents remove the wander guard which included to initiate the 1:1, someone to be with the resident all the time until they can find a long term unit to transfer the resident to. LVN B said that she was working the night shift 10 p.m. to 6 a.m. on 5/5/25 when she saw the alarm to the door was going off. LVN B said then they printed the census and checked the residents, and she said she could not remember the exact time but was after 12 midnight. LVN B said the door was alarming about this time around 12 midnight. Observation on 7/10/25 at 1:42 p.m. revealed Resident #5 with wander guard to right ankle. On 7/10/25 at 2:44 p.m., the facility administrator was notified of past noncompliance IJ. An IJ template was provided to the administrator via email at 2:48 p.m. During interview on 7/11/25 at 11:04 a.m., the Administrator stated that potential adverse effects a resident that eloped could have would include physical dangers, health complications and psychological distress. Record review of facility's policy for Elopement dated April 2017 revealed All team members will be alerted to search in the center or grounds as soon as there is an awareness of the resident missing. The policy also stated, If the resident is not quickly located in center or on grounds a point person is designated to make the following notifications: Administrator and Director of Nursing, Designated guardian or resident representative and Police (once the search of center and grounds determines the resident is not here or sooner if there is good indication they will not be located during the search). The policy also stated, Document condition notifications and times of actions deployed. Record review of the facility's undated Elopement policy if there was a resident that removed their Code Alert (wander guard) the following measures would be implemented: notification by the Charge Nurse to Administrator and DNS, Notification to Family/RP, Notification to Attending Physician and/or NP, Care Plan Conference with resident and/or RP for a secure care consult (consult for a secured/locked unit), Code Alert will be reimplemented until alternative placement, Immediate placement on one-on-one until alternative placement achieved with a secure unit and Notifications to Area Director of Operations and Regional Compliance Nurse.

Based on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was adequately supervised as a result she drank hand sanitizer and was hospitalized from 3/17/2025-3/20/2025. This failure could place residents at risk of severe injuries, require hospitalization , or death due to lack of supervision by facility staff. Findings iIncluded: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female with diagnosis of Alzheimer Disease with late onset (a progressive disease that destroys memory and important mental functions), Type 2 Diabetes, Mellitus (a chronic disease in which the body has trouble controlling blood sugar) Acute kidney failure (a condition in which the kidneys cannot filter waste), and bpolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows and manic highs). Record review of Resident #1's MDS quarterly dated 12/25/2025 revealed BIMS Summary score of 03. Section E0900- Wandering Presence and Frequency was coded as O. Behavior not exhibited. Section P0200- Restraints and Alarms revealed E. Wander/Elopement alarm was used. Record review of Resident #1's care plan dated 11/20/2019 and target date of 2/21/2025 revealed: Focus: Resident #1 was at risk for elopement related to wandering. Resident requires a wander guard for safety. Goal: Patient was not to have no incidence of elopement. Interventions: check placement and function of wander guard, evaluate effect of cognitive impairment upon resident's ability to understand changes in surroundings. Focus: Resident #1 have little or no awareness of safety, or boundaries related to other's personal space. Going into other resident's rooms, not always aware if areas are okay for her to be in, rummaging through items that are not hers. Wandering about her living space. I wander aimlessly into other residents' rooms. Staff redirects me. Date initiated 1/19/2025 revised on 2/20/2025. Goal: Resident #1 will be able to maintain a meaningful life. Interventions: If Resident #1 was wandering into other residents' rooms gently re-direct her by taking her hand and lead me into other parts of open space that offers me activities that may be engaging. Record review of elopement Risk evaluation dated 2/27/2025 revealed that Resident #1 was at risk for wandering due to her cognitive impairment and poor decision making. Record review of Resident #1's nursing progress note dated 3/17/2025 at 3:00pm, stated Resident #1 was found sipping ethyl alcohol 70% from a hand sanitizer container. The resident appeared alert. No immediate signs of distress were noted at the time of observation. Nurse immediately intervened and took the container from resident. Resident #1 was assessed fr any signs of alcohol poisoning or adverse reactions, including vital signs and level of consciousness and any complaints of discomfort. The attending physician was notified. Resident #1 was monitored closely for any potential effects of alcohol poisoning. Poison Control was contacted, and a case number assigned. Nurse was told to continue to monitor. Record review of nursing progress note dated 3/17/2025 at 4:50pm, revealed that the receptionist called the charge nurse because Resident #1 was in the lobby and hard to awaken. Nurse stated that when she arrived at the scene, the resident was having the shakes of upper extremities with her eyes opened. She was offered candy, and she asked, where was the candy?. Physician was contacted and vitals taken. Blood sugar was 201. Physician A stated to send her out to the ER. Record review of Resident #1's hospital record dated 3/17/2025 revealed chief complaint for visit was said to be drug overdose. Report stated resident #1 admitted with dementia unknown baseline who was found drinking hand sanitizer at the nursing home. EMS states unknown amount. Labs including etoh level ordered. Etoh (ethanol) is negative. Resident #1 will require admission to the IMU for close monitoring. Lab ordered stat: Ethanol Level Value <5.0 Comment: The pharmacological responses to blood alcohol levels may vary from individual to individual. The fatal concentration has been reported to be greater than 400.0mg/dl. Ethanol % <0.005 An interview with RP on 3/31/2025 @ 12:28pm, stated that she had been called about the incident when Resident #1 drank hand sanitizer. She stated that she was told that the hand sanitizer came from one of the medication carts. She said she did not recall the name of the nurse that called her. She said Resident #1 did not have a history of seizures. She stated she was aware that she had been wandering at the facility and had a wander guard. She stated that wander guard was used so she would not leave out of the door. She walked in circles both day and night. She had late-stage Alzheimer disease. She had gone into other resident's rooms a few times. She had no history of leaving the building. She said she was not a fall risk. She stated that she had been told by hospital staff that the labs showed she had a small amount of the hand sanitizer in her system, not enough to harm her. An interview with RN A on 3/31/2025 at 3:48pm stated that she had been employed for two to three weeks, and worked the 8a-5pm shift M-F. She stated that she was the unit manager. She said the charge nurse (LVN A) told her that Resident #1 had drank hand sanitizer or at least that hand sanitizer was all over her shirt. She said she called Poison Control and was provided a case number. LVN A worked Hall 4 and was familiar with the residents' behavior. She stated when she spoke with the doctor, she was told to monitor and if her vitals changed to call him back. She said LVN A called the doctor the second time to let him know she was hard to awaken and that her blood sugar was higher than normal. She said drinking ethyl alcohol could have had the resident inebriated, or it could have gotten in her eyes and that would have been bad, death if someone were to drink a whole lot of it. She was not sure what sized bottle the resident had. She stated she had conducted an in-service on 3/17/2025 about patient safety and hazardous material storage. An interview on 3/31/2025 at 4:05pm, Physician A stated that he was notified about Resident #1 drinking the hand sanitizer. He said at the time no one told him how much. He said they called poison control, and they told the nurse to just monitor. He said when they called him back about her being hard to awaken, he told them to send her out to the hospital for precaution. He said hand sanitizer could affect the liver. He said the hospital said she did not have much and was not deemed harmful at least, he repeated her labs, and they were pretty good. It is unknown how much she drank. No long-term effects from it. Labs were not abnormal from drinking the hand sanitizer. She was at her baseline. He said the only recommendation for her wandering and seeking items that might be harmful was supervising her. He said they need to monitor her closely. He said everyone knows her. Everyone was watching out for her. He said she wandered but mostly sit in the lobby. He said the key was monitoring her. An interview with LVNA on 4/1/2025 at 10:36am, she said she had been a nurse for [AGE] years. She had been an employee for about 6 months. She worked here from 2000-2005 and she just came back. She stated that CMA A alerted her that Resident #1 had drank hand sanitizer. She had it on her shirt. She talked with the unit manager (RN A); she called poison control and the doctor. She was told to monitoring her. She watched her for a change in condition. She said Resident #1 went to the front lobby to sit as she usually does then she was alerted by the receptionist that she could not awake her. She said the Resident had been in the lobby about 30-40 minutes. She said she took her vitals and blood sugar was out of baseline (200) it is not usually more than 140. She was taken to the room, and she called Physician A and he said to send her out 911. She said the hand sanitizer is usually in the locked cart. She was walking on the hall when CMA A saw Resident #1 with the bottle in her hand and it was on her chest. They assumed that she drank it. It looks like a brand-new bottle. No hand sanitizer was on her face, and she did not smell it on her breathe. When EMS arrived, she wanted to eat, and her tray was already on the tray table. She began to fight as she wanted to eat. She said she got a report from the DON that Resident #1'; s sodium was high and no trace of the hand sanitizer from the blood test. Sodium level was 160 when she got to the hospital. She does have a diagnosis of renal disease. One intervention they put in place was to give her a bottled water. She walked around with it in her hand all day drinking along the way. An interview with receptionist B on 4/1/2025 at 11:25am revealed she had been employed at the facility since January 2025. She normally worked from 3p-8p in the evening. She stated that Resident #1 normally sit in the front lobby and walk around too. She stated that she had been sitting there for 30-40 minutes on 3/17/2025. She attempted to wake her. Her eyes were opened but she was not responding. A CNA came they tried to get her up. She told the CNA to go get a nurse. LVN A came, and they got her in the chair, and she was taken to the station. They called 911 and she asked what happened because she not normally like that she normally walked a lot, sat in the lobby and then walked some more all day. She said to herself, something happened because that was not like her. She sometimes passed and got a candy from her desk. If she sat in the lobby too long, she would call the station and ask them to come get her. Interview with CMA A on 4/1/2025 at 11:56am, she said she had been employed 1.5 years and worked Hall 400 (where Resident #1) resided. She said on 3/17/2025 she saw Resident #1 coming from the back side of 400. She said the bottle of hand sanitizer was up against her mouth and turned upside down in the air (as someone drinking a beverage). She said she saw hand sanitizer on her shirt. She said that she immediately took the bottle, but Resident would not hand her the top. She said she called for the charge nurse (LVN A) to come to help her as the resident began to get aggressive with her. She said then the nurse took her into her room and took her vitals. She said as far as she was aware her vitals were normal. She said she was not aware that she was found in the lobby hard to awaken. She said she heard that later in the day. She said the hand sanitizer did not come from her medication cart as hers was still on the cart. She said the hand sanitizer was usually kept on top of the medication cart for use before passing medications. She said they had an in-service and now they must keep it inside of their carts. She said hand sanitizer is hazardous for anyone with dementia or with any ailments. Observation and Interview on 4/1/2025 at 12:12pm CMA B said she had been employed since October 2024. She worked 7a-7pm shift. She said she worked on Hall 300. She stated that she hid her hand sanitizer behind her pill crusher. Observation of a 2 oz. bottle of hand sanitizer on top of the medication cart near the pill crusher. She said she recall an in-service about keeping the hand sanitizer in the draw, but she needed to use it so often when passing medications, she just hid it. They usually have a big bottle that was kept in the side pocket on the cart. She said although there was hand sanitizer on the wall they are too far apart for her to use before passing medications. She said she did sanitizer hands before and after passing medications. An interview on 4/1/2025 at 12:25pm with Interview with NP state that he had been fat the facility for about 2 years. He stated that he had about 90 residents at the facility. He stated that Resident #1 have had recent medications changed due to the pacing/wandering. He stated that Resident #1 had bi-polar and late-stage Dementia and was on a low dosage of Zyprexa. He said a recent GDR was done for her to help with the anxiety and pacing. He stated he had not been informed about her drinking hand sanitizer. He said that if any resident drinks enough hand sanitizer it could be harmful. He said he could not speak on outcomes because he would need all the details. A telephone interview with the DON on 4//1/2025 at 2:25pm she stated no one saw Resident #1 drink the hand sanitizer to her knowledge. Then, she was told that she had a change in condition and got orders from physician A to send her out. The nurse reported to EMS that she was hard to arouse. She said hypernatremia was her diagnosis. She had been hydrated her with IV fluids and they monitored her labs when she returned. She said the hospital report indicated that she did not have any alcohol in her system. She said no staff admitted to giving Resident #1 the hand sanitizer. She did an investigation, and they immediately started an in-service immediately and made sure there was no hand sanitizer. What could have happened to her had she drunk the hand sanitizer- could cause disoriented, she is not sure about any amount of alcohol, impaired vision and cognitive impairment or inebriated. An interview with the Administrator on 4/1/2025 at 3:04pm, revealed she had been employed since September 2023. She said she found out Resident #1 had drunk hand sanitizer during their in daily clinical morning meeting the next day. She said she talked to the DON after she interviewed staff, and she said staff did not see her drink hand sanitizer. She was in the lobby, and she was unresponsive. She was sent out to the hospital. She said she saw the hospital record today and it indicated that she had 0.005% ethyl alcohol in her system. When she talked to Physician A, he was not alarmed. They also did an ad hoc qapi with their medical director. She said it reconfirmed that the resident was accessed, and the nurse had immediately called the poison control. She said Resident #1 was not symptomaticnot symptomatic. She said they never found out where the resident got the hand sanitizer. She said most staff use the dispensers affixed on the walls. She said she understood it was a small maybe 2 oz bottle, so there was not that much in the bottle. She said she was not a nurse or a doctor, so she did not know what could have happened if she had drunk more of the hand sanitizer. She said the nurse called poison control, and they took necessary measures. She said the verbal report from the DON was that she had no alcohol in her system. She said the hospital records showed that alcohol was negative. She said the DON also did in-services with staff and she will provide a copy of the in-service. A copy of the facility's Accident and supervision policy for review was requested but not received prior to exit.

Based on interview and record review the facility failed to implement their written policies and procedures that prohibit and prevent abuse and neglect for 1 of 8 residents (CR#1) reviewed for abuse and neglect. The facility failed to conduct a thorough investigation and report to State Survey agency when CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure. The facility failed to protect CR #1 for over 24 hours while awaiting results of his suspicious injury of unknown origin. The facility failed to ensure their Abuse/Neglect policy was implemented and effective to prevent the further decline of CR #1. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of serious injuries requiring hospitalization or surgical intervention, and/or death. Findings Included: Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia (paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following: Section B0600- Speech clarity- (2) no speech B0700- Ability to make self-understood (3)-Rarely or never. B0800- Ability to understand others (3)-Rarely or never Section C500- Brief Interview of Mental Status was unscored. Section G0110- Activities of Daily Living (ADL's) included: bathing, toileting, grooming and hygiene) revealed the following: A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist), B. Transfer (4-total dependence) support (3) (two-person assist), C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist) Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear. Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns. Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder. Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of progress note #1, dated 8/1/23 at 6:37 p.m., LVN A wrote: CNA A reported CR #1's knee was swollen, assessed and called MD. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room . Record review of progress note dated 8/2/23 at 10:16 p.m., CR#1 was transported to a local hospital via ambulance. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA Z all worked on 8/1, 8/2 and 8/3 and had access to CR#1 for over 24 hours. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended. Subsequent interview with DON on 9/8/23 at 5:50pm, she stated that she did conduct an interview she stated that she did start the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She denied staff being suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29pm, revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10pm, revealed her to state that she started an investigation on 8/2/23, she learned that nobody saw anything and CNA A reported the swelling on 8/1/23. She said no one was suspended. What did she do to protect CR#1 during her investigation she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVNA, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a(7/31/23), CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Subsequent interview with Interim Administrator B on 9/11/23 at 2:16pm, revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Interview with HR on 9/11/23 at 2:25pm revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin. The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm Immediate action to ensure residents were not in jeopardy and threat of harm: On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verse those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interviewable. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been prepared and submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator . The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews and physical assessments will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24am, revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility. Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, record review and interviews the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident. The facility failed to ensure that residents were free from accidents and injuries for 1 (CR#1) of 8 reviewed for accident and injuries. The facility failed to follow their policy and procedure for investigating injuries of unknown origin after both Interim Administrator A and the DON became aware that CR#1 sustained an impacted acute or subacute fracture of the supracondylar distal femur. The facility failed to thoroughly investigate CR#1 injury of unknown origin which was suspicious due him being a total care resident with an impacted fracture of the distal metaphysis of the right femur and a diagnosis of Quadriplegia. The facility failed to implement interventions to ensure CR#1 was safe after learning that his knee was swollen and was totally dependent on staff for care. The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident. An Immediate Jeopardy (IJ) situation was identified on 9/9/23 at 10:19 a.m. While the IJ was removed on 9/13/2023, the facility remained out of compliance at a scope of isolated with no actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of progress note #1, dated 8/1/23 at 6:37 p.m., LVN A wrote: CNA A reported CR #1's knee was swollen assessed and contacted physician. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., LVN A wrote: The results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room . Record review of CR #1's hospital record revealed CR#1 was admitted on [DATE] at 10:48 PM. Chief complaint was at baseline nonverbal patient with possible fracture of the right femur and swollen right knee. A pre-operative evaluation was conducted and surgical procedure to take place on 8/3/23. Observation of CR#1 on 8/4/23 at 2:40 p.m. at the local hospital revealed the resident was asleep. His right leg was wrapped with bandages from his thigh to just passed his knee. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 p.m., revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and this could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture. Interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she started the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin to State agency because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She stated that no staff had been suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that her investigation revealed that no one saw anything. She said no one was suspended because she did not find that anyone intentionally hurt CR#1. When asked how did she protect CR#1 during her investigation, she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVN A, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a on 7/31/23, CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious though and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Record review of the schedule dated 8/1/23 and 8/2/23, revealed that LVN A was scheduled as the nurse for Hall 100, CNA B worked 6a-2pm shift on Hall 100, CNA A was scheduled to work Hall 100 (2pm-10pm shift). Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA B all worked on 8/1/23, 8/2/23 and 8/3/23 and had access to CR#1 for over 24 hours. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin. Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin. The Interim Administrator B was notified of an Immediate Jeopardy (IJ) on 9/9/2023 at 10:19p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/13/23 at 1:56pm Facilities Plan to ensure compliance quickly by the following actions: The center initiated an investigation immediately upon the knowledge of the incident on 8/2/2023, concerning the fracture of the right knee for resident. After the IJ was given on 9/9/23 the interim Administrator reviewed the findings and agreed that the etiology of the fracture was inconclusive. Based on interviews with staff, residents, observation of other residents, medical record review and medical record review by the Medical Director, there was lack of evidence to support abuse and neglect. Based on the investigation, and the review, the facility is unable to substantiate abuse and neglect. Immediate action to ensure residents were not in jeopardy and threat of harm: The previous full-time administrator who was in charge of the building at the time of the incident separated employment with the center on the day following the incident. Since then, the center secured a new administrator. This administrator will assume the assignment as the center leader on 9/18/23. Until she arrives, the center will be directed by an interim administrator. On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater monthly to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02 p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12 p.m., revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, Hoyer lifts and checking for any safety issues in the facility. Interviews with five CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/13/23 at 1:56 p.m. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 residents (CR #1) reviewed for accidents and supervision and to the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking areas, and smoking safety that also take into account nonsmoking residents for 3 of 23 residents (Resident #4, Resident #5 and Resident #6) reviewed for smoking policies. The facility failed to ensure CR #1 was free of accidents and injuries causing him to sustain a impacted acute or subacute fracture of the supracondylar distal femur that required surgical procedure. Physician A and Orthopedic Surgeon said that it would require force to break and stated that something traumatic happened to the resident. 1. The facility failed to ensure Resident #4 did not have smoking materials on his person and in his room. 2. The facility failed to ensure Resident #5 did not have smoking materials in her room. 3. The facility failed to ensure Resident #7 was supervised and wore a smoking apron while smoking. These deficient practices could place residents at risk for an unsafe smoking environment and injury. An Immediate Jeopardy (IJ) situation was identified on 8/10/2023 at 1:23 p.m. While the IJ was removed on 8/18/2023 at 12:08p.m. the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could place residents at risk of severe injuries, require hospitalization , or death due to lack of supervision by facility staff. Findings included: Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following: Section B0600- Speech clarity- (2) no speech B0700- Ability to make self-understood (3)-Rarely or never. B0800- Ability to understand others (3)-Rarely or never Section C500- Brief Interview of Mental Status was unscored. Section G0110- Activities of Daily Living (ADL's) include: bathing, toileting, grooming and hygiene) revealed the following: A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist), B. Transfer (4-total dependence) support (3) (two-person assist), C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist) Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear. Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns. Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder. Record review of CR #1's care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of progress note, dated 8/1/23 at 6:37 p.m. written by LVN A, revealed CNA A reported CR #1's knee was swollen. Record review of physician orders revealed Physician A ordered a blood test and x-rays of bilateral knees for CR #1 on 8/1/23. Record review of progress note dated 8/2/23 at 12:01 p.m, RN C wrote called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of progress note dated 8/2/23 at 9:34 p.m., written by, revealed the results of the x-ray report showed a fractured femur, MD notified, ordered to send CR#1 to local hospital emergency room . Record review of progress note dated 8/2/23 at 10:16 p.m., written by LVN A, indicated CR#1 was transported to a local hospital via ambulance. Record review of radiology results for CR #1, dated 8/2/2023 at 2:19 PM, revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of CR #1's hospital record revealed CR#1 was admitted on [DATE] at 10:48 PM. Chief complaint was at baseline nonverbal patient with possible fracture of the right femur and swollen right knee. A pre-operative evaluation was conducted and surgical procedure to repair the fracture would take place on 8/3/23. Observation of CR#1 on 8/4/23 at 2:40 p.m. at the local hospital revealed the resident was asleep. His right leg was wrapped with bandages from his thigh to just passed his knee. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with LVN A on 8/4/23 at 8:40 p.m., revealed on 8/1/23, CNA A called her to the room after discovering CR #1's knee was swollen. She said she called Physician A and he asked her to send a picture of CR #1's knee. He ordered labs and an x-ray. She said the company did not come until the next day to complete the x-ray. She stated the results on (8/2/23) confirmed he had a fractured right femur. She said she sent the results to Physician A and he said to have him transported to the emergency room . Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the Medical Director was working on a clinical study on CR #1. She stated the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the injury because she said that it was not suspicious. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1 knee was swollen (8/1), and a S-Bar was put in on Wednesday (8/2/23). She said that the Director of Clinical Operation requested that the test be done stat due to his co-morbidities, but they believe his fracture was due to his osteoarthritis. She said that he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She said that LVN A was informed of the swelling from CNA A. She denied an investigation because she said that they investigate when an injury is suspicious. Interview with CNA B on 8/5/23 at 2:38 p.m., she stated she was responsible for CR #1's incontinent care and she provided bed baths. She denied using a mechanical lift with CR #1. She said she had never moved him from the bed using the lift because he never got out of the bed. She said all she would do is turn and position him. She said that she saw him last on 8/2/23. She denied his knee was swollen. Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. The interim Administrator and DON was notified of an Immediate Jeopardy (IJ) on 8/10/23 at 1:23p.m., due to the above failures, the interim Administrator was given a copy of the IJ template and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 8/13/23 at 12:43 p.m.: Immediate action taken in response to the resident's injures included the following: The resident no longer resides at the center as of 8/2/23. He has not returned to the center as of 8/13/23. When/if he returns, the IDT team will assess the resident and update the care plan. ick Compliance Actions: 8/10/23- The Senior director of Clinical Operations conducted a root cause analysis of the injury to this resident. 8/10 /23 -8/12/23- Lift evaluations were completed for all residents by the Director of Nursing and the Assistant Director of Nursing. 8/10/23- 100 % audit was completed by the Director of Nurses, Assistant Director of Nursing and Unit Manager of lift evaluations compared with the care plan to assure accuracy. Care plans were updated as needed. 8/10/23- The Director of Nurses identified the center has 20 bedbound residents in need of assist with bed mobility. The Care Plan coordinator reviewed the care plans for each of the 20 bed bound residents to ensure safety measures and interventions were added for those residents. 8/10/23-8/12/23 -Education related to Turning and Positioning, Use of Lifts, Abuse and Neglect (to include reporting any incidents), and Customer Service was continued by the Administrator, Director of Nursing and the Assistant Director of Nursing. Education regarding use of lifts was based on the manufacture's guidelines. No one will be allowed to work prior to completion of in service. The Turning and Repositioning and Lift competencies criteria will be based on instruction and a successful return demonstration. 8/10/23 The Lift for Care Policy was reviewed by Senior Director of Clinical Operations. 8/10/23- All lifts were assessed by the Maintenance Director and found to be in good working order. 8/10/23-An Ad Hoc QAPI meeting was held to discuss immediate jeopardy findings and the plan of correction going forward on August 10, 2023. Attendees were Administrator, Director of Nursing, Medical Director, Senior Director of Clinical Operations, and Regional [NAME] President. 8/12/23- Competencies for all CNAs and Nurses related to turning/ repositioning and use of lifts were initiated by the Director of Nurses and Assistant Director of Nurses on 8/12 and are on- going until all CNAS are deemed competent. As of 8/12, no CNA or nurse will work until deemed competent. Going forward to assure continued compliance with corrective actions, the Director of Nursing and Assistant Director of Nursing will conduct audits of resident positioning and lifts at least 3 times per week for one month, then 2 times per week for one month, and then weekly for one month. A QAPI PIP has been initiated to report the above monitoring and audit procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue for a minimum of three months. Monitoring of the plan of removal included the following: Interview with the Maintenance Director on 8/15/23 at 3:05 p.m., he stated he received parts for the Hoyer lifts and would be repairing 4-5 Hoyer's that were broken. Observation on 8/16/23 at 3:13pm revealed 9 mechanical lifts were operable and in good repair. The lift from Hall 100 was included in the nine repaired due to a broken brake. Interviews with multiple anonymous staff between 8/15-8/16/23 revealed they were not able to state if the mechanical lift training was conducted one-on-one or in group setting, demonstration completed or just a verbal training and when/if they had abuse, neglect and exploitation training. More interviews were conducted. Interview on 8/17/23 at 12:17pm with the DON, VP of Operations (VPO), VP of Clinical Operations (VPCO), and Interim Administration revealed staff were not consistent in what recent in-services and/or demonstration they had in the past week. The DON stated she would ensure everyone had been re-educated before working a shift. This task would be completed by 8/18/23. Interviews on 8/17/23 and 8/18/23 with 2 LVN's, 1 RN and 3 CNA's, housekeeping, floor tech and maintenance on the 6a-2pm and 2p-10pm shifts were interviewed and had been trained on reporting incidents of abuse, neglect, exploitation, falls, and use of mechanical lifts and safe transfers. Staff reported that the Interim Administrator was the Abuse Coordinator, all incidents or falls should be reported immediately to nursing administration, and they had been in-serviced on using the mechanical lift properly by Therapy Director. Interviews on 8/18/23 at 8:24am, with two overnight (10p-6am) CNAs stated that they received training on the lift, repositioning and abuse reporting. Interview with the DON on 8/18/23 at 11:15am, revealed her to state that all but four employees had been trained on the re-positioning and mechanical lift competencies. She said that two were on vacation and the two were not scheduled to work the week of 8/28-9/1/23. She said that she would ensure they were trained before working on the floor. Interview with the Therapy Director on 8/18/23 at 11:55am, revealed him to state that he provided training on properly using the mechanical lift, turning and repositioning for all CNA's on 6a-2pm and 2pm-10pm shifts. He stated that the overnight charge nurse would train the CNA's and provide documentation to the DON. Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended. Record review of the list of bedbound residents included 20 residents were deemed bedfast had updated care plans. Record review of in-services on 8/17-8/18/23 revealed abuse, neglect and exploitation, reporting incidents, turning and repositioning competencies and EZ way smart lift competencies were completed by all but 4 staff. Record review of an undated lift care policy revealed the total lift will be used when residents were non-ambulatory and residents could not bear weight or if they did not qualify for the sit-to stand lift. The Interim Administrator, DON and RVP were informed the Immediate Jeopardy was removed on 8/18/23 at 12:08pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. A second supervision issues was discovered on 8/11/2023 at 12:40pm Findings Included: 1. The facility failed to ensure Resident #4 did not have smoking materials on his person and in his room. 2. The facility failed to ensure Resident #5 did not have smoking materials in her room. 3. The facility failed to ensure Resident #7 was supervised and wore a smoking apron while smoking. These deficient practices could place residents at risk for an unsafe smoking environment and injury. Findings Included: Record review of the facility list of smokers revealed there were 23 smokers who resided at the facility. Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #4 had diagnoses which included spinal stenosis (spinal narrowing often caused by age-related wear and tear) , abnormality of gait(an usual walking pattern), polyarthritis(when at least five joints are affected by arthritis), presence of left artificial knee joint. Record review of Resident #4's care plan, dated 4/12/2022 and revised on 8/19/2023, revealed Resident #4 was at risk for smoking related injuries related to attempts to obtain lighters or matches and a history of smoking incidents. Intervention: Resident is not to have cigarettes or smoking material on person. Record review of nursing progress note, dated 8/12/23, revealed the DON must be notified if Resident # 4 is non-compliant with the facility's smoke policy. Observation from the items from Administrator, DON and ADON room sweep on 8/11/23 at 2:17 p.m., revealed the administration team found the following: Resident #4 had a Ziplock bag of cigarette filters, 2 packs of buglers (loose tobacco used for rolling into a cigarette) and 6 lighters found in his room. Interview with Resident #4 on 8/11/23 at 3:04 p.m., revealed he always kept his cigarette filters and materials with him. He stated as a resident he should be able to keep his smoking material. He said he smoked at least 5-6 times per day. He stated that the former Administrator was going to discharge him. But they could not discharge him without him having someplace to live. He said he guessed that they could not find anywhere else for him to go. Resident #5 Record review revealed Resident #5's face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #5 had diagnoses which included: Lack of coordination, Abnormality of gait and mobility (change to normal walking pattern), cognitive communication deficit, schizoaffective disorder (a combination of symptoms of schizophrenia and mood disorder), infection and inflammatory reaction due to internal prosthetic devices, implants or grafts. Record review of progress note dated 8/12/23, for Resident #5 revealed the DON was to be informed if she should be incompliant with the facility's smoking policy. Observation on 8/11/23 at 12:40 PM, revealed Resident #5 was smoking a cigarette. No staff was outside at the time. Observation of items from the sweep on 8/11/23 at 2:17 p.m., revealed 2 packs of cigarettes and a lighter was found in Resident #5's room. Interview with Resident #5 on 8/11/23 at 3:07 p.m., revealed her to state that she did not have anything to say. Record review of Resident #7's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #7 had diagnoses which included: Chronic systolic (congestive heart failure), Chronic kidney disease, Diabetes Mellitus uncontrolled, Schizophrenia, Hypertension, Dysphagia, Abnormality of gait and mobility, muscle wasting in right and left shoulders. Record review of Resident #7's smoking assessment dated [DATE] revealed in section D. Summary of evaluation 1. Based on the above evaluation the resident will require supervision with smoking the answer was (1) Yes. Goal: Will have no smoking related injury. Interventions: place patient in position to assure visualization of ashtray, provide smoking apron while smoking, review smoking policy and storage of smoking materials per center policy. Record review of Resident #7's care plan, dated 6/22/23, revealed the resident was at risk for smoking related injury related to his inability to manage ashes and non-compliant with smoking policies, refuses to wear apron and smoking outside of schedule. Interventions: 6/22/23- Provide smoking apron while smoking. 8/15/23-Resident requires supervision while smoking. 8/21/23-refused to wear smoke apron during smoke break. Observation on 8/11/23 at 12:40 p.m., revealed Resident #7 was smoking in the smoking area unsupervised and without a smoking apron. Interview with the ADON on 8/11/23 at 12:47 p.m., revealed her to state that the residents should not have been smoking unsupervised, and it was not their smoke times. She was at the nursing station at the time. But she stated that she did not see them going out there. She said different staff are scheduled to supervise the residents at each smoke time. Interview with CNA E on 8/11/23 at 1:45 p.m., revealed the residents were aware of the smoke times, they should not have been out there. He said they were also sharing cigarettes because Resident #4 left the facility and got his cigarettes and shared them with other residents. Interview with Resident #6 on 8/11/23 at 1:49 p.m., he stated although he was sitting out in the smoking area he was not smoking earlier when the State Surveyor was getting the names of the residents that were unsupervised. He stated they all knew the smoke times and the facility threatened the residents with 30-day notices but did not kick them out because they did not have anywhere else to go or they did not want to leave. He said they continued to do whatever they wanted to do and smoked anytime they pleased. Interview with the DON on 8/11/23 at 2:00 p.m., revealed she was aware there was an issue with compliance of the smoke policy. She said since day one of her employment she learned it was a problem in the facility (July 2023). She said they had given discharge notices and yet the residents still smoked when they should not be smoking. She said she would provide those discharge notices. Interview with the Interim Administrator on 8/11/23 at 2:00 p.m., revealed they would conduct a sweep of the rooms to search for cigarettes and lighters and report their findings. Interview with the RVP on 8/11/23 at 2:00 pm, revealed administration would meet resident council, all smokers and give them discharge notices if necessary for them to adhere to the smoking policy. During an interview with Resident #7 on 8/12/23 at 1:03 p.m., he stated he wanted to know when the State Surveyor would be leaving the facility. He stated he used to smoke when he wanted. He stated he had to sign himself out to smoke outside of the facility smoke times. He said he did not wear an apron because he did not want to. Record review of the facility's, undated, smoke policy revealed: In order to protect all residents at the facility the following smoking policy must be strictly enforced by Team Members and adhered to by all residents and families and visitors. 1. Resident must smoke in designated area at posted times. Smoke times are: 8:30- 9:00am (Activity supervise) 11:00am- 11:30am (Nursing supervise) 1:30pm-2pm (Nursing supervise) 3:30pm-4:00pm (Activities supervise) 6:45pm-7:15pm (Station 1) 2. Residents may not have cigarettes, cigars, matches, lighters, light fluid, in their possession or in their rooms at any time. 6. Smoking privileges will be suspended entirely if a resident becomes harmful to self and others. Non-compliance with the facility smoking policy will lead to discharge. Record review of the facility's Safe Smoking policy, effective date: November 1, 2016, revealed .(4) Staff members will monitor or obtain fire igniting materials (matches/lighters) for the benefit of smokers at the nurses' station or other designated locations.

Based on record review and interview the facility failed to thoroughly investigate and report an injury of unknown origin for 1 (CR #1) of 8 reviewed for abuse and neglect. The facility failed to thoroughly investigate CR #1 injury of unknown origin which was suspicious due him being a total care resident with an impacted acute or subacute fracture of the supracondylar distal femur and a diagnosis of Quadriplegia. The facility failed to implement interventions to ensure CR #1 was safe after learning that his knee was swollen and was total dependent on staff for care. The facility failed to report the results of all investigations to officials in accordance with state law, including to State agency within 5 working days of the incident. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. This failure could have placed residents at risk of abuse and neglect. Finding Included: Record review of census provided on 8/4/2023, revealed a census of 101 residents. Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of progress note #1, dated 8/1/23 at 6:37 PM, revealed CNA A reported CR #1's knee was swollen to LVN A. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room . Record review of progress note dated 8/2/23 at 10:16p.m., CR#1 was transported to a local hospital via ambulance. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of the schedule dated 8/1/23 and 8/2/23, revealed that LVN A was scheduled as the nurse for Hall 100, CNA B worked 6a-2pm shift on Hall 100, CNA A was scheduled to work Hall 100 (2pm-10pm shift). Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA B all worked on 8/1/23, 8/2/23 and 8/3/23 and had access to CR#1 for over 24 hours. Interview with the hospital charge nurse on 8/4/23 at 3:07 p.m., revealed the leg injury caused CR #1 to require a surgical procedure. She said he had a broken right femur, lateral collateral ligament (LCL) repair, washout, and open reduction internal fixation (process of putting pieces of a broken bone into place using surgery). She stated it was in her professional experience as a registered nurse that the resident was not capable of falling out of bed on his own. She said he was not able to move his limbs. She said whatever happened to him took force. She said that she was unable to say if it was abuse. She said the resident had not grimaced or shown any facial expressions since she had been observing him today (8/4/23). Interview with an anonymous nurse at the local hospital on 8/4/23 at 3:32 pm, revealed her to state that it appears that someone intentionally hurt him. She said, off the record, the charge nurse might not have said that, but everyone that has cared for him at the hospital felt like someone did this to him. She said as a mother this would be very upsetting to her. She said that she felt like he was abused. Interview with the FM on 8/4/23 at 8:11 p.m., revealed that she received a call from LVN A (8/2/23) concerning CR #1's knee being swollen and later a call from LVN A that the lab results confirmed the resident had a fractured femur. She stated she inquired about what happened to CR #1. She said LVN A stated she was not sure, but the first report of a swollen knee was on 8/1/23. She said LVN A refused to say anymore. She denied talking with any other administration or nursing staff concerning the injury. She said the surgeon told her the longest and strongest bone in the bone was broken along with ligaments in his knee had to be repaired. The FM stated the surgeon said whatever happened to him required force to break his femur. She said that the admitting physician told her that it is difficult to break this bone. She said that she believes that someone at the facility intentionally hurt him, and she is very upset about him being treated in this way. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with Physician A on 8/8/23 at 3:05 p.m., revealed he received a call and/or text from LVN A on 8/1/23 concerning CR #1's swollen knee. He stated he ordered blood work to rule out gout and rheumatoid arthritis and an x-ray of right bilateral knee. He said the resident did not have evidence of gout or rheumatoid arthritis. He said osteoarthritis would not cause a fracture. He said given CR #1's age of 25, and the fact he did not have any diagnosis that would cause a fracture of the femur, he was baffled at how something like this could have happened. He stated CR #1 had been under his care since he was admitted to the facility (1/13/22) and have not had any seizures. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with the Orthopedic Surgeon on 8/9/23 at 1:29 p.m., he stated he conducted surgery on CR #1's femur and repaired ligaments on the outside of the patella on 8/3/23. He said he did not understand how the largest and strongest bone in your body could be fractured. He said especially since he was not ambulatory and was total care. He said CR #1 had a supra condylar femur fracture which is very complex fracture. He said that it required quite a bit of force to break. He said something traumatic happened to the resident for such as break to occur. He said he has osteoarthritis himself, but it would not cause this type of fracture. Interview with Interim Administrator B on 9/8/23 at 5:47p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended due to no staff admitting any falls or trauma. She said that it is also believed that if CR#1 had fallen he would have other injuries. Interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she started the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin to State agency because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She stated that no staff had been suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that her investigation revealed that no one saw anything. She said no one was suspended because she did not find that anyone intentionally hurt CR#1. When asked how did she protect CR#1 during her investigation, she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVN A, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a on 7/31/23, CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Subsequent interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious though and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Interview with HR on 9/11/23 at 2:25 p.m. revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin. The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm Immediate action to ensure residents were not in jeopardy and threat of harm: On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, reporting incidents, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility. Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on record review and interview the facility failed to develop and implement policies and procedures for ensuring the reporting of reasonable suspicion of a crime for 1 (CR #1) of 8 residents who was total care and sustained a femur fracture. 1. The facility failed to thoroughly investigate and report to State Survey agency that CR #1, who was a total care resident, sustained a supra condylar femur fracture and required surgical procedure.On 8/2/23 the resident was sent to the hospital and it was confirmed to be a supracondylar acute or subacute fracture. This suspicious injury of unknown origin should have been reported to the Administrator immediately. Interim Administrator A was not made aware of the incident until 8/3/23 a day later. Meanwhile the staff that had assisted CR#1 continued to work and no investigation was started. Interim Administrator A did not conduct an investigation. 2. The facility failed to ensure all allegations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown origin were reported to State Agency for 1 (CR #1) of 8 reviewed for abuse and neglect. This failure could have placed 101 residents at risk of abuse and neglect. An Immediate Jeopardy (IJ) situation was identified on 9/8/2023 at 5:37 p.m. While the IJ was removed on 9/12/2023 at 1:09 p.m., the facility remained out of compliance at a scope of isolated with actual harm due to the facility's need to evaluate the effectiveness of the corrective system. Findings Included: Record review of census provided on 8/4/2023, revealed a census of 101 residents. Record review of CR #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. CR #1 had diagnoses which included: Quadriplegia(paralysis of all four limbs), injury of cervical spinal cord, contracture of left and right hand(condition that causes one or more fingers to bend towards the palm of the hand), contracture of muscle(a fixed tightening of muscle, tendons or ligaments), acute respiratory failure with hypoxia (impairment of gas exchange between the lungs and the blood), flexion deformity(the inability to straighten or extend the knee), stage 4 pressure ulcer on spine(injury to skin and underlying tissue resulting from prolonged pressure on the skin) and epilepsy(disorder of the brain). Record review of CR #1's quarterly MDS assessment, dated 6/17/23, indicated the following: Section B0600- Speech clarity- (2) no speech B0700- Ability to make self-understood (3)-Rarely or never. B0800- Ability to understand others (3)-Rarely or never Section C500- Brief Interview of Mental Status was unscored. Section G0110- Activities of Daily Living (ADL's) included: bathing, toileting, grooming and hygiene) revealed the following: A. Bed Mobility - total dependence (4) required full staff performance every time during 7-day period with support (2)- (one-person physical assist), B. Transfer (4-total dependence) support (3) (two-person assist), C. Walk in room by self- 8 (never happened), toilet use -total dependence (4) support -(1-person assist), Bathing (4-total dependence)- support (1-person assist) Section G0130- Functional Status revealed CR #1 was dependent - helper did all effort. Resident did none of the effort to complete activity for eating, oral hygiene, toileting hygiene, shower/bathe, upper body dressing, lower body dressing, and putting on or taking off footwear. Section G0170- Mobility revealed CR #1 was dependent on staff (01) for roll left and right, sit to lying, lying to sitting on side of bed, chair/bed, chair transfer and sit to stand. Code 01- dependent- Helper does all of the effort. Resident did none of the effort to complete the activity. Toilet transfer, car transfer, and walk 10 feet were coded (88) for not attempted due to medical condition or safety concerns. Section H0300 - Urinary Incontinence revealed CR #1 was (3) always incontinent of bowel and bladder. Record review of care plan, dated 6/17/23, revealed CR #1 had an ADL self-care performance deficit r/t traumatic brain injury and spinal cord injury. Interventions were transferring required total assistance with mechanical lift and two-person staff assistance and bed mobility required extensive assistance by (2) staff to turn and reposition. Record review of progress note #1, dated 8/1/23 at 6:37 p.m. LVN A wrote: CNA A reported CR #1's knee was swollen, assessed and contracted physician. Record review of progress note dated 8/2/23 at 12:01p.m., RN A wrote: Called to follow up with local x-ray company on orders for bilateral patella X-ray and was informed that the order was in dispatch status. Record review of radiology results for CR #1, dated 8/2/23 at 2:19 p.m., revealed the resident had an impacted acute or subacute fracture of the supracondylar distal femur. Conclusion: Fracture of the distal right femur. Record review of progress note dated 8/2/23 at 9:34 p.m., revealed the results of the x-ray report showed a fracture femur, MD notified, ordered to send CR#1 to local hospital emergency room . Record review of progress note dated 8/2/23 at 10:16p.m., CR#1 was transported to a local hospital via ambulance. Record review of CR#1 facesheet, careplan dated 6/17/2023 and MDS dated [DATE], revealed that CR#1 had no diagnosis of Osteoarthritis and no care plan interventions for the disease. Record review of the facility's abuse, neglect policy, dated 1/2019, revealed the purpose is to prohibit and prevent abuse, neglect and exploitation of resident property and to ensure reporting and investigation of alleged violations (to include injuries of unknown source, mistreatment and involuntary seclusion) in accordance with Federal and State Laws. Definitions: Injuries of Unknown origin source: When both criteria are met: the source of the injury was not observed, or the source could not be explained by the resident and the injury is suspicious because of the extent of the injury or the location of the injury (i.e. the injury is located in an area not generally vulnerable to trauma). Protection: First and foremost, the resident/patient will be immediately assessed and removed from any potential harm. The results of all investigations must be reported to the Administrator, designee to the appropriate state agency, as required by state law, within five (5) working days of alleged violation. Record review of punch detail report dated 8/1/23- 8/4/23 provided by HR revealed that LVN A, CNA A and CNA Z all worked on 8/1, 8/2 and 8/3 and had access to CR#1 for over 24 hours. Interview with the Interim Administrator A on 8/5/23 at 12:11 p.m., revealed he was a traveling Administrator and his 1st day of work at the facility was on 8/3/23. He said that he was just made aware of the incident on 8/3/23. He stated he did not call in an incident to State Agency. He said that the Administrator is responsible for investigating and reporting incidents of unknown origin. However, the DON and ADON can investigate and call in an incident as well. He said that incidents not investigated or reported to State agency can leave residents vulnerable to abuse, neglect or exploitation. Interview with the Director of Clinical Operations on 8/5/23 at 2:03 p.m., revealed the lab results revealed CR #1 had osteoarthritis and his contractures made him vulnerable to losing bone density and thus could have caused his fracture. She denied investigating the incident of unknown origin because she said that it was not considered suspicious. She denied reporting the incident of unknown origin to the State Agency. Interview with the DON on 8/5/23 at 2:06 p.m., revealed LVN A reported CR #1's knee was swollen (8/1/23), and a S-Bar was put in on Wednesday (8/2/23) once the results came back and informed them of his fracture. She said the Director of Clinical Operation requested the test be done stat due to his co-morbidities, but they believed his fracture was due to his osteoarthritis. She said he was sent to the emergency room for care. She said there were no reports of CR #1 falling or trauma. She denied an investigation because she said they investigated when an injury was suspicious. She stated she had not called the State Agency because she was not sure if the former Administrator had called it in. She said the Administrator was not the only person who could call in an incident of unknown origin. She said, I guess any nurse could have called the incident in to State agency. Interview with CNA A on 8/8/23 at 3:23 p.m., revealed she had been off three days prior to 8/1/23. She stated upon her return to work she was doing rounds and noticed CR #1 right knee was swollen. She said it was like a large grapefruit. She said she immediately called LVN A into the room to observe. She said she had not tried to transfer or change the resident. She said she checked his brief to see if the previous shift had changed him and that is when she saw his knee as she pulled back the covers. She denied witnessing him fall or any trauma. Interview with Interim Administrator B on 9/8/23 at 5:47 p.m., revealed her to state that when she first learned about the incident, she was told that CR#1 had co-morbidities that could have caused the injury, but that the DON started an investigation. She stated that she did not think any staff had been suspended. Subsequent interview with DON on 9/8/23 at 5:50 p.m., she stated that she did conduct an interview she stated that she did start the investigation process by getting statements from staff. She did not call in CR#1 injury of unknown origin because she said that it was not suspicious. She stated that she should have called it in to the State because now she understands how it was could have been considered suspicious. She denied staff being suspended pending an investigation. She said that she had no evidence to accuse anyone. She stated that she does understand that she was supposed to protect CR#1 while investigating. Interview with LVN A on 9/10/23 at 12:29 p.m., revealed her to state that she worked on 8/1 (day CNA reported CR#1 swollen knee), 8/2/23 (day results confirmed fracture) and worked Hall 100 (where CR#1 resided) on both days. She admitted that she had not been sent home or suspended. She was not aware of an investigation, but she said she wrote a statement and documented the progress note as they are required to do. Subsequent interview with DON on 9/11/23 at 2:10 p.m., revealed her to state that she started an investigation on 8/2/23, she learned that nobody saw anything and CNA A reported the swelling on 8/1/23. She said no one was suspended. What did she do to protect CR#1 during her investigation she responded, He was already gone, we sent him to the ER after getting the results. She was asked if the same staff (LVNA, CNA A and CNA P had access to CR#1 and she responded, she was not sure without looking at the schedule. But, she should have suspended the CNA that worked overnight 10p-6a (7/31/23), CNA P (worked 6-2pm shift on 8/1 and 8/2) , CNA A (reported the swollen knee 2-10pm shift on 8/2). She was unable to say why she did not protect CR#1 as their policy requires. Subsequent interview with Interim Administrator B on 9/11/23 at 2:16 p.m., revealed her to state that she was not working here at the time, but she began an investigation of her own. She stated that because of his osteoarthritis no one suspected abuse. She said that she can understand how this incident could be viewed as suspicious and thus called for a thorough investigation and reporting. She said she would report the incident to State agency immediately. Interview with HR on 9/11/23 at 2:25 p.m. revealed her to state that she was not informed to suspend any employees due to CR#1's injury. She stated that the ADM or DON would be the two managers that would suspend employees if there was an investigation and determined that staff were going to be investigated. She stated that she had been employed with the company since May 2023. Record review of the DON's, undated, job description responsibilities states: (1) DON assumes responsibility of facility in absence of Administrator. (2) Works in collaboration with the center; ensures education and understanding by all team members of abuse recognition, protecting and reporting responsibilities; responds swiftly to any allegation of abuse, neglect or misappropriation by protecting, investigating and making any required reporting. Record review of TULIP on 8/9/23 and 9/9/23 revealed no incident report was found concerning CR #1's injury of unknown origin.The Interim Administrator B and DON was notified of an Immediate Jeopardy (IJ) on 9/8/2023 at 5:37p.m., due to the above failures, the Interim Administrator B was given a copy of the IJ template, and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 9/9/23 at 3:20pm Immediate action to ensure residents were not in jeopardy and threat of harm: On 9/8/23, the Administrator and the DNS immediately took the following actions to address the citation to prevent any additional residents from experiencing an adverse outcome. On 9/8/23, the DNS and her designee conducted medical record reviews of all residents to identify which residents were interview able verses those that could not be interviewed. BIMS scores were collected to determine those residents that could be interviewed verses those that were considered non interview able. On 9/8/23, the DNS and her designees completed physical assessments of all residents with a BIMS score of less than 11 to determine if there was evidence or abuse or injury of unknown origin. Assessments of these resident revealed no such evidence of abuse or injury of unknown origin. Documentation of these assessments was captured on an assessment tool and placed in the survey binder. This action was completed on 9/8/23. On 9/8/23, the DNS and her designees interviewed each resident with a BIMS of 11 or higher to assure they had not been abused or experienced an injury of unknown origin. Interview of these residents was captured on an interview tool and placed in the survey binder. Neither evidence of abuse nor injury of unknown origin was identified through interviews or body audits. This action was completed on 9/8/23. If evidence of abuse or injury of unknown origin had been identified, the Administrator would have suspended any accused staff and reported the incidents to the state and law enforcement in accordance with the State law and licensing agency requirements. A detailed investigation would have been conducted and the results submitted within 5 days of the negative findings. On 9/8/23, the Regional [NAME] President and the Senior Director of Clinical Operations provided training for the interim administrator and the Director of Nurses regarding abuse identification, protection, conducting a thorough investigation and reporting requirements. This action was completed on 9/8/23. Following the Adm and DNS training on 9/8/23, training on the center's abuse and neglect policy was initiated by DNS and her designee to include identification of abuse, protections of residents, investigation and reporting requirements. The DNS completed training on the morning of 9/9/23 for all staff that were working on the evening and night shifts. This training will continue until all staff are training. Employees will not be allowed to work until they have received this training. Facilities Plan to ensure compliance quickly by the following actions: All federal and State protocols will be followed going forward to include investigating and reporting abuse and injury of unknown origin allegations. The ADM is designated as the Abuse Coordinator. The Administrator was in-serviced on abuse identification, protection, conducting a thorough investigation and reporting requirements by RVP and Senior Director of Clinical Operations. This action was completed on 9/8/23. On 9/8/23, Residents with BIMS scores of 11 or higher were interviewed by the DNS and her designees to identify in they felt safe and if they had experienced abuse while living at the center. No concerns were identified. These interviews were completed on 9/8/23. On 9/8/23, the Abuse policy was reviewed by the Regional [NAME] President and the Senior Director of Clinical Operations. This review was completed on 9/8/23. No updates were necessary. On 9/8/23, Interim Administrator implemented an abuse investigation checklist to ensure investigations will be initiated and completed thoroughly. On 9/8/23, the DNS and her designee educated all staff on abuse prevention and reporting. This education was completed on 9/8/23. Going forward, any staff that were not present on 9/8/23 will not be allowed to work until they have been trained. On 9/9/23, the Activities Director will hold a Resident Council meeting in which the residents will be educated on the facility's abuse policies. This council meeting will conclude on 9/9/23. The Administrator or designee will continue to interview residents with a BIMS score of 11 or greater on a monthly basis to ensure they have not experienced abuse. 5 residents per week will be interviewed for 3 months starting the week of 9/11/23. The Director of Nursing or designee will conduct physical assessments on 5 residents per week with BIMS score of less than 11 to determine if there is evidence of abuse or injury of unknown origin for 3 months starting the week of 9/11/23. The findings of these interviews will be presented in QAPI as a PIP project. On 9/9/23, the Regional Director of Maintenance will conduct an environmental safety concern assessment of the center. This assessment will be completed by the center's maintenance director or the administrator on a weekly basis for 3 months beginning the week of 9/11/23. The findings of these assessments will be presented in QAPI as a PIP project. Competency of staff related to the Abuse/Neglect training will be captured by a competency test after each training. These competencies will continue until all are trained and deemed competent. Monitoring of the plan of removal included the following: Record review of in-services revealed that abuse, neglect, expliotation, including injuries of unknown origin, turning and repostioning, lift and transfers, customer service, reporting incidents and abuse coordinator acknowledgements were conducted. Interview with the Interim Administrator B on 9/10/23 at 11:24 a.m., revealed her to state that BIM scores were pulled from MDS and she compared with the census to ensure every resident was either deemed interviewable (BIM score above 11) or required a body audit if BIM score was under 11. She provided a list of the residents that were interviewed and those that they conducted body audits on. Interview with Activity Director on 9/10/23 at 12:02p.m., revealed her to state that she conducted a resident council meeting with the residents, and none of the residents had any concerns about abuse, neglect or misappropriations. She said that she had a training and in-service on abuse and neglect, reporting incidents, professionalism, transfers, smoking policy. Interview with two housekeepers on 9/10/23 at 12:07p.m., revealed them to state that they had an in-service on abuse, neglect, reporting if they see someone mistreating the residents to report it to the Administrator or DON. Interview with Maintenance and Regional Maintenance on 9/10/23 at 12:12pm, revealed them to state that on a daily basis they are checking the building for safety hazards such as: fire extinguishers, doors, outlets, hoyer lifts and checking for any safety issues in the facility. Interviews with CNA's on all three shifts, LVN A, two housekeepers, one floor tech, one MA, two charge nurses and maintenance and they all stated that they had been in-serviced on abuse, neglect and exploitation, reporting abuse and told if they had witnessed abuse they would report it to the Administrator. The Interim Administrator B was informed the Immediate Jeopardy was removed on 9/12/23 at 1:09pm. The facility remained out of compliance at a severity level of actual harm that is not IJ and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. Record review of TULIP on 9/14/23 revealed a provider's report dated 9/12/23 with findings of inconclusive for the allegation of injury of unknown origin.

Based on observation, interview and record reviews the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 2 of 8 residents (Resident #2 and Resident #3) reviewed for Activities of Daily Living. 1. The facility failed to ensure Resident #2's received incontinent care since the previous day which resulted in his adult brief, sheets and bed soaked with urine. 2. The facility failed to ensure Resident # 2 was given scheduled showers. 3. The facility failed to ensure Resident #3's adult brief was clean and dry. These failures could place residents at risk of embarrassment, discomfort, and skin breakdown. Findings included: Resident #2 Record review of Resident #2 face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included: dementia, hypertension, hemiplegia and hemiparesis following cerebral infarction (stroke-occurs when there is a disrupted blood flow to the brain) affecting left side, contracture of left wrist, pain in left shoulder, and Type 2 diabetes (condition that affects the way your body uses sugar). Record review of Resident #2's quarterly Minimum Data Set (MDS), dated [DATE], section C500 BIM summary score of 11 (means moderately impaired). Section G0110 Activities of Daily Living assistance revealed (A) Bed mobility - Limited assistance needed with one person physically assisting. G0120- Bathing required physical help in part of bathing activity with one staff. Section G0300- Moving on and off toilet (8) for activity did not occur. Section H0300- Urinary Incontinence (3) Always incontinent. Record review of resident care plan, revised of 5/12/23, revealed Resident #2 had an ADL self-care deficit due to previous CVA with residual left side hemiparesis and contracture in left hand. Interventions would be to anticipate and meet the resident's needs. Observation of Resident #2 on 8/13 at 2:46 p.m., revealed he had a urine odor and soiled brief. Observation of Resident #2 on 8/16/23 at 11:11 a.m., revealed he had a soiled brief, sheets and the bed was soaked with urine. Interview with Resident #2 on 8/13/23 at 2:46 p.m., revealed his brief was wet and no one was in to change him since about 5am. He stated that he was told by an unknown CNA that she would be back. However, she did not come back. Interview with Resident #2 on 8/16/23 at 11:11 a.m. revealed staff did not check on him often nor changed his brief as needed. He stated despite him pressing the call light, staff usually told him they would come back and never return. He stated he had not had a shower since the previous week on Thursday (8/10/23). He said he should have a shower every Tuesday, Thursday and Saturday. He stated it was very embarrassing that he smelled due to staff not changing him and not getting showers on the days he was supposed to get them. He said he wanted to leave the facility because they were not providing services he was paying for. Interview with the Charge Nurse A on 8/16/23 at 11:17 a.m., revealed she would check to see what staff were responsible for residents on the hall (Hall 300). She stated, This does not make any sense that he was this soaked with urine. She removed the sheets off him and requested Nurse C come to observe. She stated CNA E was responsible for caring for the resident today and did not provide incontinent care for Resident #2. She said she would ensure Resident #2 received a shower and linen was changed because there was no excuse for him not being changed or showered. She said the resident required assistance with incontinent care and showers. CNA's are responsible for bathing and incontinent care of the residents. She said keeping the residents' briefs dry lowered their risk of skin breakdown. Interview with CNA D on 8/16/23 at 12:07 p.m., revealed CNA E was responsible for Resident #2's room. Interview with CNA E on 8/16/23 at 1:18 p.m., revealed someone called in and no one told him to cover Resident #2's room. He stated he had not been in Resident #2's room at all during his shift which was 6AM-2PM. He said that the schedule usually had what rooms each staff were responsible for daily. Resident #3 Record review of Resident #3 face sheet revealed an 85- year-old female that was admitted to the facility on [DATE] with diagnoses which included Alzheimer Disease (a progressive disease that destroys memory), Dementia (a thinking and social symptoms that interferes with daily functioning), Dysphagia (impairment in the production of speech from brain disease), and severe cognitive communication deficit. Record review of Resident #3's annual MDS revealed in section C500-BIM score was 0. Section H0300- Urinary Incontinence (3)- Always incontinent. Record review of the care plan dated 5/24/22 and revised date of 4/13/23 revealed Resident #3 had an ADL self-care deficit due to Alzheimer's disease and abnormality of gait and mobility. Bed mobility: The resident required assistance by 1 staff to turn and reposition. Bathing and showering- The resident required physical help by 2 staff with bathing. Observation on 8/16/23 at 11:19 a.m of Resident #3 revealed she had a strong urine odor. There were no sheets on the bed. Interview with Resident #3 on 8/16/23 at 11:19 a.m., revealed she was not interview able. Interview with Charge Nurse on 8/16/23 at 11:22 a.m., revealed her to state the resident was sometimes combative, but she should still receive incontinent care as needed. She removed the sheet off the resident and stated she was wet, and she would get staff to change her. Interview with the ADON on 8/16/23 at 1:17 p.m., revealed she was unaware two residents were found in wet soiled briefs and that Resident #2 had not had a shower in 3 days. She said that she would look into it and find out why they had not been changed as needed and why Resident #2 had not been showered according to his care plan.

Based on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 16 residents (CR #1) reviewed for quality of care. -The facility failed to ensure CR #1 returned to the Orthopedic Clinic for a follow-up appointment post right hip surgery in three weeks from the date last seen on 11/18/2021. -The facility failed to start CR #1 on oral antibiotics when CR #1 had completed her IV antibiotic regimen as recommended by the Orthopedic Clinic on 11/18/21. -The facility failed to obtain wound cultures on CR #1's right hip as ordered by the NP on 12/03/21. CR #1 had to be transferred to the hospital due to altered mental status and increase drainage from the right hip on 12/17/21. CR #1 had to return to surgery for [MEDICAL RECORD OR PHYSICIAN ORDER] An Immediate Jeopardy (IJ) was identified on 02/15/22 at 10:48 a.m While the IJ was removed on 02/18/2022 , the facility remained out of compliance at a severity level of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and a scope of isolated, due to the facility's need to evaluate the effectiveness of their Plan of Removal (POR). These failures could place residents with surgical wounds at risk for serious wound infections, harm, or death. Findings Included: CR#1 Record review of CR #1's face sheet revealed a [AGE] year-old female admitted on [DATE] with the following Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's Care Plan dated 10/15/21 revealed she was care planned for altered skin integrity non pressure related: surgical wound to right upper and lower hip present upon admission with the following interventions: *Observe for signs and symptoms of infection such as swelling, redness, warm, discharge, odor, notify physician of significant findings. *Treatments as ordered. Record review of CR #1's MDS dated [DATE] revealed CR #1's BIMS score was 9 indicating cognition level was moderately impaired. Further review revealed CR #1 required extensive assistance with bed mobility, dressing, toileting, and personal hygiene. Further review revealed CR #1 was frequently incontinent of urine and always incontinent of bowel. Record review of CR #1's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] *[MEDICATION(S)] (antibiotic) 1gm intravenously every 12 hours for right hip infection, date of order 10/16/21 with end date 11/11/2021. *[MEDICATION(S)] (antibiotic) 1000mg intravenously every 12 hours for infection, date ordered 10/20/21 with end date 11/12/21. *[MEDICATION(S)] 50mg give 1 tablet by mouth every 8 (eight) hours as needed for chronic pain and give 1 tablet by mouth every 8 hours for pain, order dated 11/15/21. *C&S of right hip one time, date ordered 12/03/21. Record review of the MAR for November 2021 revealed CR #1 received [MEDICATION(S)] 1gm intravenously from 10/16/21to 11/11/21. Further review of the MAR revealed CR #1 received [MEDICATION(S)] 1gm intravenously 10/20/21 to 11/12/21. CR #1 was not receiving any oral antibiotics. Record review of the TAR for December 2021 revealed on the 5th LVN C documented the C&S of the right hip was collected. Record review of CR #1's outpatient Orthopedic Clinic report dated 11/18/21 revealed in part: .To whom it may concern .CR #1 was seen in our clinic today for her orthopedic injuries .CR #1 states that her IV antibiotics were discontinued a week ago and is unsure if she was receiving any antibiotics orally at this time. If her IV antibiotic regimen has completed, she needs to continue oral antibiotics at this time .We will plan to see her back in 3 weeks for repeat evaluation at that time. If possible, the patient should bring in pictures of her lateral wound after her wound vac changes for evaluation at her next appointment . Record review of CR #1's Progress Notes dated 11/18/21 at 1:20 p.m. documented by LPN D (with no mentioning of CR #1 returning to clinic in 3 weeks) read in part: .CR #1 returned from appointment with orders to continue oral antibiotics . Record review of the 24-hour report from 11/18/21 through 12/17/21 revealed no documentation of a follow-up appointment with the Orthopedic Clinic, recommendation of oral antibiotics after CR #1 completed IV antibiotics, or to obtain culture of CR #1's right hip. Record review of CR #1's Progress Notes dated 12/03/21(Friday) at 8:46 a.m. documented by LPN D revealed in part: .CR #1 alert and responsive to verbal and physical stimuli, able to make needs known .CR #1 complain of pain to right hip .[MEDICATION(S)] 50mg given as ordered for pain .CR #1 stated doing exercise with therapy causing pain to her right hip .LPN D assessed right hip, blood tinged dressing at incision site, 3 sutures noted to open area .LPN D changed dressing site .LPN D notified therapy regarding exercise .LPN D notified the M.D., X-ray to right hip ordered . Record review of a radiology exam report of CR #1's right hip dated 12/03/21 revealed the following: No acute fracture or dislocation, no acute abnormalities. Record review of CR #1's Progress Notes dated 12/3/21 at 10:43 a.m. late entry documented by the NP revealed in part: .The patient's care was discussed with the nursing staff on duty. Nursing report discharge from hip that is foul smelling . Further review of CR #1's Progress Notes dated 12/17/21 at 10:32 a.m., by NP revealed in part: .The patient care was discussed with the staff on duty. The patient noted with altered mental status and increase discharge from right hip wound along with foul smell . Record review of CR #1's Hospital Transfer Form dated 12/17/21 at 2 p.m., revealed the reason for transfer was altered mental status. Record review of CR #1's hospital records revealed admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review revealed that CR #1 was take back to surgery on 12/18/21 for incision and drainage of the right hip. Interview on 01/11/22 at 10:00 a.m., the Wound Care Doctor said he came to the NF on a weekly basis. The Wound Care Doctor said CR #1 was not on his list of residents to see at the NF. The Wound Care Doctor said if a resident had a surgical wound, he would not be providing care unless due to COVID and the surgeon was unable to see the resident and the resident needed to be seen. The Wound Care Doctor said the surgeons provided care for their own residents or patients. Interview on 01/11/2022 at 10:20 a.m., the Administrator said CR #1 was still in the hospital. The Administrator said she did not know the details of why CR #1 had to be transferred to the hospital other than CR#1 had experienced a change in condition and would have to view CR #1's records. Interview on 01/11/2022 at 10:25 a.m., the OT said CR #1 was receiving therapy prior to her discharge. The OT said approximately 3 weeks prior to CR #1 being admitted to the hospital, CR #1 had shared in her last therapy session, her whole body ached. OT said herself and CR #1 agreed to do less repetitions with her exercise and the OT said she reported to the PT what CR #1 had shared with her. The OT said the PT was in agreement with the exercise regimen of doing less repetitions. The OT said on the day CR #1 was transferred to the hospital, during therapy, CR #1 was hurting all over especially in her back and lower body area. Interview on 01/11/2022 at 11:20 a.m., LVN A said when CR #1 resided at the NF, the previous DON was working at the NF and the NF had an interim DON at present time. LVN A said it was the DON and ADON who coordinated the resident (s) doctor appointments. LVN A said she did not know if CR #1 returned to her follow-up doctor appointment with the surgeon after seeing the surgeon on 11/18/2021. LVN A said the NF had two treatment nurses, RN B and LVN C that provided care for wounds in the NF that were stageable wounds or surgical wounds. LVN A said the nurses on the units provided care for minor wounds such as skin tear or abrasions. LVN A said all the nurses could place a dressing on a wound if the dressing came off. LVN A said RN B worked Monday through Friday. LVN A said RN B no longer worked at the NF and believed stopped working at the NF sometime during the Thanksgiving or Christmas Holidays. LVN A said LVN C still worked at the facility and worked Saturday and Sunday. Interview on 01/11/22 at 12:11 p.m., a call was placed to the Orthopedic Physician Office regarding CR #1. The Investigator spoke with staff Medical Assistance, who said the last time CR #1 was seen in the Orthopedic Office was 11/18/21 and according to records, CR #1 had to go to surgery on 12/18/21 for a right hip infection with purulent drainage (white, yellow, or brown fluid sometimes thick in texture, unpleasant smell, sign of infection) requiring incision and drainage. The Medical Assistance said CR #1 was discharged from the hospital on 01/04/22 and while viewing records, did not reveal where CR #1 was discharged too. Interview on 01/11/22 at 12:35 p.m., the NP said he had been an NP for [AGE] years and made rounds at the NF on Friday's. The NP said CR #1 was admitted to the NF with a right hip surgical wound and IV antibiotics that she had completed. The NP said the last time he saw CR #1's wound, it looked infected draining pus secretions with a foul odor. The NP said he did not recall reviewing CR #1's Orthopedic Surgeon Notes on 11/18/21. The NP said he relied on the nurses to communicate to him regarding resident doctor visits. The NP said he was not responsible for treating CR #1's infection, but had given a verbal order to get an X-ray of CR #1's right hip as well as a C&S of CR #1's right hip. The NP said when he returned to the NF the next week, he saw that the C&S of the right hip was not done. The NP said in retrospect, could have taken the next step and reached out to the Orthopedic Surgeon to clarify what antibiotic to prescribe for CR #1. Interview on 01/11/22 at 1:00 p.m., RN B said she used to work Monday through Friday from 8am-5pm, she said she stopped working at the NF on 12/1/21. RN B said when a resident came back from a doctors appointment, the nurse on the unit would provide a copy to her most of the time entailing the residents visit to the doctor. RN B said most of the time, she would take it upon herself to view the communication of the resident doctor visit to see if there were any recommendations. RN B said the nurse on the unit would reach out to the PCP or NP letting either one know what recommendations were suggested. RN B said if there were any recommendations, usually the PCP or NP would address the recommendations. RN B said she did not remember seeing anything about oral antibiotics for CR #1 after her Orthopedic visit on 11/18/21 and if she had, she would think that the surgeon wanted to placed CR #1 on oral antibiotics after completing her IV antibiotic regimen as a prophylactic measure given the history of infection to CR #1's right hip. Interview on 01/11/22 at 1:23 p.m., LPN D said she worked at the NF full time on the 6a-2p shift. LPN D said typically when a resident with a wound and required a wound vac, it was usually the treatment nurse who coordinated the follow-up doctor appointments. LPN D said when CR #1 returned from her Orthopedic Doctor visit, she had reached out to the NP regarding the recommendations for oral antibiotics via text when he did not respond to her call. LPN D said when she contacted the NP via text regarding the recommendations for oral antibiotic, the NP responded okay. LPN D said on 12/3/21 (Friday), CR #1 was receiving physical therapy and had medicated CR #1 for pain, but it was not effective and therefore reached out to the NP. LPN D said she had asked the NP for an X-ray order due to CR #1 complaining of a lot of pain to make sure that CR #1's hip was not dislocated. LPN D said the NP gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . LPN D said the NP never gave her an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 01/11/22 at 2:00 p.m., LVN A said after reviewing CR #1's records, a C&S of CR #1's right hip was not done. Interview via phone on 01/11/22 at 2:10 p.m., the previous DON said he stopped working at the NF on a Friday and did not recall CR #1. The DON said the NF had meetings regarding any changes in resident (s) condition. The DON said it was the nurses on the units that were responsible for coordinating a resident follow-up. The DON said if the unit nurse was unable to coordinate the resident doctor appointment, he would intervene to assist provided if the information was relayed to him. The DON said before RN B stopped working at the NF, RN B was the buffer in between the nurses on the units in coordinating resident(s) doctor appointments and follow-up appointments. The DON said when RN B stopped working at the NF, LVN C would have been the one to step up to ensure that the resident(s) were going to their follow-up doctor appointments. The DON said the NF communicated on the 24-hour report in the computer regarding resident care. The DON said if the nurses did not communicate the resident doctor visit in the computer on the 24-hour communication, it was missed. The DON said some of the nurses were still trying to write the communication on paper instead of the computer. The DON said himself and the ADON would follow-up in the computer on any new communications. The DON said regarding the recommendations for oral antibiotics for CR #1, the nurses on the unit or the NP could have reached out to the Orthopedic Clinic for clarification. The DON said the NP that was caring for CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said because the NP knew he was coming to the facility to make rounds and thought he would take care of or address the issue but end of not addressing the issue. The DON said he would have reached out to the doctor in the past to let the doctor know the issue was not addressed. Interview on 02/15/2022 at 10:48 a.m., the interim DON said she started working at the NF on 01/10/22. Interview on 02/15/2022 at 11:15 a.m., LVN A said the NF viewed CR #1's records again and the NF did not start CR #1 on oral antibiotics after completing her IV antibiotic regimen. LVN A said the facility did not obtain a C&S of CR #1's right hip nor did CR #1 go for her follow-up appointment with the Orthopedic Surgeon. LVN A said it was the nurses on the units that received the paperwork when a resident returned from an appointment. LVN A said the unit nurse were the ones who coordinated resident appointments and follow-ups as well as the ADON. Interview on 02/15/2022 at 11:22 a.m., the Administrator said the ADON no longer worked at the NF. Interview on 02/16/21 at 11:25 a.m., Clinical Operations said although LVN C documented on the MAR that a C&S was done on CR #1's right hip on 12/05/21, there was no records to show that it was done. Interview on 02/16/2022 at 11:46 a.m., the ADON said she stopped working at the NF before Christmas. The ADON said she remembered CR #1 having a wound vac. The ADON said her responsibility while working at the NF included viewing the resident (s) medical records when first admitted to the NF. The ADON said the nurse on the unit transcribed the resident (s) physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ADON said the NF had started going paperless therefore, if received a verbal order, would transcribe directly in point click care. The ADON said if this was not done, it could get missed. The ADON said it was the nurse on the unit that coordinated the resident (s) doctor appointments. The ADON said if the nurse on the unit was having issues in coordinating a resident doctor appointment, the DON or ADON stepped in to assist with the process. The ADON said when a doctor sent back a communication form of the resident visit, it is given to the nurse on the unit and that nurse is responsible in communicating any recommendations or new orders as well as setting up follow-up transportation for follow-up doctor appointments by communicating with the doctor office and in house transportation. The ADON said the treatment nurses were responsible for obtaining wound cultures after the unit nurse informed the treatment nurse a culture was needed. The ADON said someone at the NF should have followed with the Orthopedic Clinic regarding oral antibiotics. The ADON said the NF had morning meetings discussing what events took place over the prior day and night as well as weekends. The ADON said the recommendations from the Orthopedic Clinic should have been mentioned on the 24-hour communication form. The ADON said she thought in November, the NF was still using the paper method for 24-hour communication regarding the resident (s) status. Interview via phone on 02/16/22 at 12:55 p.m., LVN C said she worked the weekend shift as the NF treatment nurse. LVN C said she obtained a culture of CR #1's right hip over the weekend on a Sunday (12/05/21). LVN C said she did not follow-up on the results of the culture because she just worked the weekend shift and therefore when she returned to work, she assumed it had been taken care. LVN C said she was not aware of CR #1 needing to follow-up with the Orthopedic Clinic or of the recommendations of CR #1 needing to be on oral antibiotics after completing her IV antibiotics. Interview on 02/17/2022 at 11:40 a.m., LPN D said she no longer worked at the NF. LPN D said she stopped working at the NF 2-3 weeks ago. LPN D said she did not recall setting up a follow-up appointment for CR #1 with the Orthopedic Clinic but did remember texting the NP regarding recommendations for oral antibiotics if done with IV antibiotics. LPN D said when a resident returned from a doctor visit and required a follow-up appointment, the nurse on the unit called transportation after confirming the follow-up appointment date to schedule transportation. LPN D said the nurse then put the actions taken on the 24-hour report sheet. LPN D said she never saw an order to obtain a culture on CR #1's right hip. Interview on 12/18/2022 at 12:15 p.m., the NF Medical Director said he heard about what happened regarding CR #1. The Medical Director said it was clearly the communication of care for CR #1 had fallen through the cracks. The Medical Director said he had a meeting with the Administrator to ensure that would not happen again. The Medical Director said moving forward, when a resident (s) return from a doctor visit requiring a follow-up appointment, the staff is required to communicate in point click care so the appointment does not go missed. The Medical Director said the NF could have reached out to the Orthopedic Clinic to see what oral antibiotic could have been prescribed for CR #1 or the NF could have done a culture of CR #1's right hip to see what bacteria was growing and treat. Record review of the NF Policy on Neglect revised 2019 revealed in part: .Failure of the center, its team members or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress . The Administrator was notified on 02/15/22 at 10:48 AM that an Immediate Jeopardy (IJ) situation had been identified due to the above failures. The IJ template was provided to the Administrator on 02/15/22 at 11:00 AM. The following Plan of Removal (POR) was submitted by the NF Administrator and was accepted on 02/16/22 at 8:48 AM: [NAME] Oaks Healthcare & Rehabilitation Center Plan of Removal 2/16/2022 Immediate Actions: ¢ CR#1 was discharged on [DATE]. Review of the medical record completed to determine root cause analysis of missed follow up appointment, recommendations, and labs ¢ Residents with surgical and pressure wounds were reviewed for ABT and appointments to ensure being scheduled and completed as ordered. No additional concerns were noted ¢ A lab audit was conducted to determine if there were any additional missed labs. ¢ All current resident appointments have been reviewed for potential omissions. None noted. ¢ All current resident appointments were reviewed to assure all recommendations have been acted upon. ¢ The above audits were completed by Interim Director of Nursing Services; Director of Clinical Education and Director of Clinical Operations on 2/15/2022. ¢ Current residents with surgical or pressure/arterial/venous ulcers wounds will be assessed for s/s of infection on 2/16/2022 with the Wound MD from Vohra. All findings will be documented in the progress notes by the Wound Care MD. Systematic Education Completed: ¢ Licensed Nursing Team members were educated on receiving lab orders, orders for appointments, and other recommendations from the Director of Clinical Education and the Director of Clinical Operations on 2/15/2022. ¢ Going forward, the nurse will assure that all orders received from outside appointments, including labs and recommendations are recorded in the electronic medical record. All recommendations will be called into MD for further instructions if any. ¢ When taking orders for outside appointments, the order will go under the Lab description. The licensed nurse will check daily for appointments on the EMAR to ensure completed for the day. Nurse will document when resident leaves and returns from appointment. Nurse will document in medical record progress note section status of resident discharge and return from appointments. If resident has new orders they will be communicated with the MD/NP and documented in the medical record. ¢ When the nurse is given orders for labs, they will be put under the Lab description. The nurse will check daily to ensure that labs are completed as ordered. If resident refuses the lab, the MD/NP will be notified for further follow up. ¢ In daily clinical review all new orders will be reviewed to ensure that they have been completed and results reported to MD/NP and documented in the medical record. ¢ During Clinical Review, the DNS or her designee will verify pending orders for labs and follow up appointments are completed as required. The DNS or designee will ensure the lab and/or appointment has been scheduled; in regard to an appointment the DNS or designee will ensure transportation has been scheduled and all notifications of pending lab and or appointment has been communicated to RP as needed. If a resident refuses the lab or appointment, the MD/NP will be notified for further follow-up. All licensed nursing team members were provided education on the expectation and the new process of handling follow up appointments and recommendations. The education and training were provided on 2/15/2022 by the Director of Education and the Director of Clinical Operations. Currently the facility does not utilize agency currently. Director of Clinical Education will educate all new hires and document education of these expectations during the orientation process before a new licensed team member is allowed to accept a schedule. For any applicable nursing team members who are currently off or on leave, The Director of Clinical Education will in-service those team members prior to their working their next shift. ¢ QAPI: A focused QAPI meeting addressing the finding was initiated and completed on 2-15-2022 with the attendance of the Administrator, DNS, Director of Clinical Operations, Regional Director of Operations and Medical Director. The focused QAPI reviewed procedures for resident outside appointments; labs; and new orders from outside appointments to ensure all areas were addressed. Going forward, the QAPI members will review all outside appointments to assure recommendations have been followed as ordered weekly for 4 weeks and then monthly for 2 months. Any variance from the recommendations will be corrected immediately and addressed in QAPI. The center acted swiftly with the corrective actions, team member re-education, and ensured auditing measures were in place to monitor the plan. The center utilized the QAPI process to address the identified deficient practice immediately and completed actions on or before 2-15-2022. Monitoring was initiated on 02/17/22 at 1:20 p.m. Interview on 02/17/22 at 1:20 p.m., LVN F said she had received in-services on labs (how to document in point click care, how to run the report on labs), resident doctor appointments, and communicating with the physician and family regarding resident (s) care. LVN F said she had also been in-serviced on documenting in point click care a resident (s) follow-up appointments, setting up transportation for doctor visits, and to following up that task had been completed. Interview on 02/17/22 at 1:25 p.m., LVN G who worked the 6a-2p shift said had been in-serviced on resident follow-up appointments and how to document in PCC, arrange transportation, documenting task in PCC. LVN G said when a resident returned from a doctor appointment to document in the Progress Notes any recommendations or new orders, labs were to be transcribed in PCC and in 24-hour communication in PCC. Interview on 02/17/22 at 1:30 p.m., LVN H who worked the 6a-2p shift said she had been in-serviced in the following areas; abuse and neglect, transcribing orders in PCC to flag in the computer. LVN H said when order was flagged it would stay yellow until the task had been carried out. LVN H said she was in-serviced on following up with labs that were ordered and to communicate with the physician of the results. LVN H said she was in-serviced on transcribing resent doctor appoints in PCC where all shifts could view. Interview on 02/17/22 at 2:00 p.m., LVN I who worked the weekend shift said he had been in-serviced on transcribing orders in PCC and to follow-up to ensure it was done and communicated to the physician as well as resident doctor appointments and recommendations or new orders. LVN I said he was also in-serviced on setting up transportation and communicating all on the 24-hour communication that was done in PCC as well. Interview on 02/17/22 at 2:15 p.m., LVN K said she worked the weekend shift. LVN K said she had be in-serviced in the following areas; transcribing all orders in PCC as well as doctor appoints and follow-ups along with any recommendations, following up on lab results and communicating to the physician, and documenting in PCC as well as Progress Notes communicating with all shifts to ensure all orders were being carried out. Interview on 02/17/22 at 2:20 p.m., RN L said she was a treatment nurse that worked 4p-8p and had been working at the NF for 2 months. RN L said she had received in-services on following up on resident appointments, communicating with the doctor and NP, entering all orders and doctor appoints in PCC under the lab section, if a resident lab or doctor appointment was missed communicate that to the doctor and NP, document all resident appointments going or coming utilizing the 24-hour communication form in PCC. Interview on 02/17/22 at 3:00 p.m., RN M said he worked the 2p-10p shift and had been in-serviced on doctor appointments ensuring all visits were being communicated and carried out, setting up doctor visits and transportation for the resident (s), transcribing all labs and doctor visits in PCC so that all disciplinaries could see it, and ensuring that all labs were being done with follow-up communicating with the doctor/NP of the results documenting in the Progress Notes. Interview on 02/17/22 at 4:25 p.m., LVN C she had been in-serviced in resident with follow-up appointments ensuring that all recommendations with the doctor office was communicated with the doctor or NP and placing those communications/recommendations in PCC, if resident had a follow-up appointment be sure to set up transportation, carrying out all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/17/22 at 6:50 p.m., RN O said she said she worked the 2p-10p shift Monday through Friday. RN O said she had been in-serviced on transcribing all resident(s) with doctor appointment and follow-up appoints in PCC under lab section, following up on all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/17/22 at 7:00 p.m., LVN MM said she the night shift 10-6p. LVN MM said she had been in-services on transcribing all physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 02/18/22 at 12:45 a.m., RN Q said she worked the 10p-6a shift. RN Q said she had been in-serviced on transcribing physician orders, carrying all orders out, and communicating all test results to the doctor. RN Q said she also had been in-serviced on transcribing doctor appointments and follow-up appointments in PCC under labs and setting up transportation of resident(s) with doctor appointments ensuring all had been carried out. Interview on 02/18/22 at 10:50 a.m., RN P said he worked the weekend shift 6a-6p. RN P said he had been in-serviced in the following areas; transcribing all orders, doctor appointments, transportation for resident(s) with appointments outside of the facility documenting in PCC and the Progress notes. On 02/18/22 at 12:45 PM, the NF Administrator was notified the Immediate Jeopardy (IJ) was lowered. However, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective system.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accidental hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of ten residents (Resident #2) reviewed for accidents and supervision. The facility failed to provide adequate supervision and a safe environment free of safety hazards for Resident #2, who was cognitively impaired with a history of multiple falls and resulted in a serious injury. This failure placed cognitively impaired residents at risk of experiencing serious injuries from falls. Findings included: Record review of Resident #2's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with Alzheimer's Disease, dementia, acute kidney failure, diabetes, functional [CONDITION(S)] (the complete inability to move due to severe disability or frailty caused by another medical condition), cognitive communication deficit, muscle wasting and atrophy, [CONDITION(S)] (persistent problems falling and staying asleep), contracture of left and right knees, anxiety, fall from bed-subsequent encounter, contusion of scalp-subsequent encounter, contusion of left eyelid and periocular area-subsequent encounter, and contusion of head-subsequent encounter. Resident #2 was discharged to a local acute care hospital on 01/17/2022 and returned to the facility on [DATE]. Resident #2 passed away in the facility in the facility on 02/05/2022. Record review of Resident #2's MDS dated [DATE] revealed she was rarely/never understood, no BIMS was conducted; her cognitive skills for daily decision making were moderately impaired; she required extensive physical assistance from at least one staff member for bed mobility, dressing, toilet use, personal hygiene, and locomotion, and total staff assistance with bathing; she was wheelchair bound and she was always incontinent of bowel and bladder. Record review of Resident #2's care plan, updated 01/01/2022, revealed she was admitted to hospice care on 01/25/2022 related to end of life care and changes in condition; she had an ADL self-care performance deficit due to muscle weakness and Alzheimer's Disease; she required total assistance on her wheelchair; she had impaired cognitive function due to Alzheimer's Disease; she was at risk for falls due to gait/balance problems; she had actual falls without injury related to unsteady gait on 03/06/2020, 09/12/2020, and 10/29/2020; she had an actual fall from bed without injury on 08/06/2020; she had a fall from wheelchair after attempting to reach for her ice water on a table in front of her on 08/13/2021; she had a fall from bed while reaching for the stuffed animal at bed side table without injury on 01/14/2022; she had a fall sliding out of the wheelchair without injury on 01/15/2022; and she was observed on the floor beside her bed, agitated with a hematoma in the left forehead and was sent to the hospital for further evaluation on 01/17/2022 (Interventions included: Anticipate and meet the resident's needs: 04/29/2019, Be sure the resident's call light is within reach and encourage the resident to use it for assistance. The resident needs prompt response to all requests for assistance: 04/19/2019, Bed will remain in lowest position at all times: 08/06/2020, Educate the staff about safety reminders and what to do if a fall occurs: 04/29/2019, Review information on past falls and attempt to determine cause of fall. Record possible root causes. Alter/remove any potential causes if possible: 04/29/2019, The resident needs a safe environment with even floors free from spills and/or clutter, adequate glare-free light, a working and reachable call light, the bed in low position at night: 04/29/2019, Ensure that stuffed animal is with her in bed so she does not need to reach out for it and have a fall: 01/20/2022, Wheelchair assessment will be conducted by rehab department due to wheelchair safety and prevention of falls: 01/20/2022, Staff will ensure all items are within reach of resident when up in wheelchair: 08/13/2021, Bed may remain in lowest position at all times except with ADL care: 10/29/2020, Monitor/document/report PRN to doctor for signs and symptoms of pain, bruises, change in mental status, new onset confusion, sleepiness, inability to maintain posture, and agitation: 09/11/2019, Perimeter mattress so resident cannot fall from the edge of the bed: 01/21/2022; Resident will be in view of staff with door open, in central area when up in wheelchair except with meals: 10/29/2020) Record review of an incident report dated 01/14/2022 revealed LVN H wrote, Resident fell from bed to floor while reaching for stuffed animal at bedside, fall witnessed. Resident did not hit head. Resident assessed; no injury noted. Vital signs stable . MD/NP notified. When asked by writer what happened, resident pointed to stuffed animal while on floor. Once assessed and placed back into bed resident stated, [thank you mama] . Witnesses - No witnesses found . Record review of Post Fall Review (fall assessment) completed by LVN H dated 01/14/2022, revealed, 1. Date and time of fall: 01/14/2022, 5:45 p.m., 2. Activity at time of fall: Bed to floor, 3. Location of fall: in resident's room, 4. Prior to fall, patient was: In Bed, Reaching out, 5. Patient's explanation of how they fell , if able to communicate: pointed to stuff animal on floor, resident was reaching out, 6. Objective/underlying factors: History of falls (if selected, document details below), 6a. resident has dementia and is unaware of safe judgement . Recommendations/Interventions: Wheelchair positioning/seating devices, Evaluation of Footwear, Change in Footwear, Change in footwear, Night light, Bed in low position, Recliner chair, Mechanical lift for transfer, Toileting schedule, Physical Therapy, Perimeter mattress, Safety cues/reinforcement/reminder, Assistive device within reach, Signage- Stop sign, Evaluate timing of medications, Occupational Therapy, Daily nap, Restorative program, Psych Evaluation, Medical Evaluation, Anti-tippers, Pain assessment, Body pillow (s) for positioning, Wider mattress, Drop seat in wheelchair, Anti-rollback brakes, Wheelchair brake extensions with tops painted orange for additional visual cues, Medical Review, Evaluate Activity Program and encourage participation . Record review of an incident report dated 01/15/2022, revealed RN P wrote, CNA reported resident slipping off her wheelchair, landing on the ground on her left shoulder. Patient alert, denied pain, no signs of pain noted, no bruise on both shoulders. Immediate Action Taken, Description: Assisted patient back on wheelchair and back to her room and put in bed . Witnesses - No witnesses found . Record review of, Post Fall Review (fall assessment) completed by LVN A dated 01/15/2022, revealed, Date and time of fall: 01/15/2022, 2:51 p.m., 2. Activity at time of fall: Chair to floor, 3. Location of fall: nurse station, 4. Prior to fall, patient was: Other, 5. Patient's explanation of how they fell : sitting in wheelchair at nurse station, 6. Objective/underlying factors: History of falls (if selected, document details below) - 6a. fell yesterday . Recommendations/Interventions: Wheelchair positioning/seating devices, Evaluation of Footwear, Change in Footwear, Change in footwear, Night light, Bed in low position, Recliner chair, Mechanical lift for transfer, Toileting schedule, Physical Therapy, Perimeter mattress, Safety cues/reinforcement/reminder, Assistive device within reach, Signage- Stop sign, Evaluate timing of medications, Occupational Therapy, Daily nap, Restorative program, Psych Evaluation, Medical Evaluation, Anti-tippers, Pain assessment, Body pillow (s) for positioning, Wider mattress, Drop seat in wheelchair, Anti-rollback brakes, Wheelchair brake extensions with tops painted orange for additional visual cues, Medical Review, Evaluate Activity Program and encourage participation . Record review of an incident report dated 01/17/2022, at 3:00 p.m., revealed LVN H wrote Summoned to resident's room by CNA due to resident observed on the floor with brief off and in process of removing her shirt. Bed observed in lowest position, resident assessed, hematoma observed to left forehead, above eyebrow. Agitation noted, resident remained conscious and verbal. NP notified; Alert Medical Response called for transport to ER. Cold compress applied to hematoma and resident medicated with Tylenol due to possible pain . unable to explain: Dementia . Mental Status . Alert times 1, remained conscious but unable to express pain .Level of Pain: 2 . Facial Expression - Score 2: Facial Grimacing . Witnesses - No Witnesses found . Record review of Resident #2's hospital records revealed she was admitted on [DATE] and discharged back to the facility on [DATE]. The document read in part, . History of Present Illness: . presents to the emergency room after she had a witnessed fall from the bed. She fell from the bed while trying to get up and dressed. That happened around 3 p.m. in the afternoon. She immediately noticed to have left periorbital hematoma and a black eye. She was sent to the ER for further evaluation . Assessment/Plan: 1. Accidental fall from bed 2. Closed head injury 3. Contusion of scalp (left scalp hematoma, no intracranial bleed or trauma noted, Facial bone CT unremarkable) . In an interview with LVN A on 01/26/2022 at 11:00 a.m., she stated Resident #2 was normally pleasantly confused, she spoke English off and on (mostly Spanish), she had a little stuffed animal that she said was her baby, and she thought everyone was her daughter. LVN A said recently, Resident #2 took everything off, including her diapers and clothes. She said they told Resident #2 to put everything back on and she said ok, but then she took it all off again. She said Resident #2 was not ambulatory and required staff assistance to transfer to her wheelchair. She said Resident #2 could sometimes push herself in her wheelchair, but she did not walk. She said Resident #2 scooted while she was in her wheelchair and staff had to tell her to scoot back. She said in bed, Resident #2 scooted to one side of the bed while laying down. She said taking her shirt and brief off was normal for Resident #2 (for about four months) but it was not normal for her to fall. LVN A said on that day (01/17/2022), during shift change (around 2:00 p.m.), she was putting boxes outside the milk room door (which was almost directly across the hall from Resident #2's room) and she heard Resident #2 yell out, Mommy! She said CNA R was coming up the hall and heard the resident yell too. She observed CNA R peep her head into Resident #2's room and then called to LVN A that she was on the floor. She said she, CNA R, and LVN H all went into Resident #2's room and found her on the floor, faced-down with her arm inside her shirt (it looked like she was trying to take it off) and her brief was on the floor. She said when they turned Resident #2 over, she had a hematoma over left eyebrow. She said they tried to talk to her in Spanish, but she just rambled and did not answer question. She said she and the other staff found Resident #2 between her bed and the nightstand and the hematoma looked like and egg. She said they put Resident #2 in bed, they started doing vitals, called the doctor, then they called transport to take her to the hospital. She said since Resident #2 returned from the hospital, she had not been as talkative as she was before the fall. LVN A said when they got Resident #2 up in her wheelchair, she tried to get up and do stuff. She said Resident #2 was in a low bed when she fell and nobody else was in the room but her roommate (who was bed bound and not cognitively abled to participate in an interview). She said CNA R had just given Resident #2 care and commented that the resident kept taking her brief off when she came out of the room. CNA R told her Resident #2 was laying in the bed when she left her room. LVN A said Resident #2 could still move around when she wanted to and could put herself in a sitting position from laying. In an interview with LVN H on 01/26/2022, at 11:30 a.m., she said Resident #2 had a baby doll she liked to carry, and she tried to reach for it, so the staff kept it close to her. She said since Resident #2's fall on 01/17/2022, she would not eat, and she refused her medication. She said on 01/17/2022, her shift was over, and she was about to go home when CNA R came back up the hall to get her jacket and asked her to go to Resident #2's room because she was on the floor. She said she and the other staff turned Resident #2 over and saw she had a large hematoma, like she may have hit her head on something. She said LVN A was two doors down and went in first. LVN H said Resident #2's brief was off and, on the floor, and it looked like the resident was trying to get her shirt off when she fell . She said she called transportation and told them it was an emergency, so they were there in less than 20 minutes. She said CNA R went into Resident #2's room first, then when she went in, she saw the resident was down on her face. She said Resident #2 she was moving and squirming like she was trying to get her clothes off. She said when CNA R rolled Resident #2 over, they immediately saw a large hematoma and she said, Jesus Christ! LVN H said Resident #2 was in a low bed at that time and she would often have to redirect her from trying to get up. She said she and the aides would get her up into her wheelchair, but they knew she was always ready to go back to bed. She said when Resident #2 returned from the hospital, she saw that her face was all bruised. She said now, they have to monitor Resident #2 closely. In an interview with CNA R on 01/26/2022 at 11:50 a.m., she said she usually cared for Resident #2. She said Resident #2 was sometimes agitated and fussy and she had not been able to self-propel in her wheelchair for the last couple of months. CNA R said Resident #2 sometimes tied to get up and get on the edge of bed, so they got her up. She said Resident #2 could go from lying to sitting position by using the quarter rails at the head of her bed. She said that day (01/17/2022), Resident #2 was agitated, she did not want to eat, and she kept getting out of her brief and gown. She said at the end of her shift, she put Resident #2's gown and brief on and left her laying in her low bed. She said she was getting ready to leave and realized she forgot her jacket in the room next to Resident #2's. She said there was only about five minutes between the time she left Resident #2's room and when she returned to find her on the floor. She said she did not hear Resident #2 yell, just looked inside her room as she passed and saw her on the floor. She said she called for LVN H and LVN A to come and when they turned Resident #2 over, they saw a hematoma on her eye. She said Resident #2 fell in front of the nightstand that was beside her bed. CNA R said Resident #2 was so small that it may have looked like she was between the bed and the nightstand with her right side was down. She said Resident #2 was just repeating, Mommy. She said they asked Resident #2 if she was in pain, but she said no. Observation and interview with Resident #2 and CNA R on 01/26/2022, at 12:15 p.m. revealed Resident #2 was asleep and laying in a low bed with plastic bumpers on each side (perimeter mattress). Resident #2's bed was against the wall on her left and there was a nightstand to the right with approximately one foot of space between the nightstand and the bed. Resident #2's face was bruised with dark purple across her cheeks, nose, and under her eyes. Both of her eyes were dark purple. Resident #2 had a very large hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) that was dark purple to her left forehead. There was a small scab on the tip of the hematoma. Resident #2's top lip and the area under her nose were dark purple. CNA R demonstrated where Resident #2 was found on the floor on 01/17/2022. CNA R pointed and said Resident #2's head was found slightly between the bed and nightstand. Resident #2 woke up at that time and just looked. Resident #2 did not respond to questions, but she kept saying, alright when questioned. Resident #2 grabbed CNA R's hand several times and kissed it. CNA R said Resident #2 had on a hospital gown on 01/17/2022. In an interview with the Physical Therapist on 02/18/2022 at 12:15 p.m., she said physical therapy had just discharged Resident #2 on 01/13/2022, before she started falling again in January. She said they were about to pick Resident #2 up again and the wheelchair assessment to see about getting her a new one was scheduled for the day she went out to the hospital. She said she recalled hearing at the morning meeting the day after Resident #2 fell out of her wheelchair (01/15/2022) while she was sitting in the TV room (which was located near a nurse's station and the physical therapy room). Unsuccessful attempts were made to contact RN P by phone and text on 02/18/2022 at 11:04 a.m. and 02/24/2022 at 12:20 p.m. In an interview with Interim DON on 02/18/2022 at 3:22 p.m., she said she was familiar with Resident #2 because she fell in the first week she started working at the facility. She said when Resident #2 fell on [DATE], her stuffed doll was out of reach, so the intervention was to make sure all of her things were within reach either in the bed or on the table. She said Resident #2's next fall was when she slid out of her wheelchair, but she could not recall if it was witnessed. Interim DON said for Resident #2's next fall, she was sent out and the intervention was a perimeter mattress. She said environmental assessments were done with fall assessments and it was routine to look at everything. She said she could not say if the environmental assessment was documented on the fall assessment. She said everything was taken into consideration with falls, including height of bed and environmental factors. She said the nightstand was not the cause of either of Resident #2's falls and they would not have care planned to move the table because the staff used it to feed her and keep her things close. Record review of facility policy dated February 2017, titled, Falls revealed, Purpose, To establish a process that identifies risk and establishes interventions to mitigate the occurrence of falls . Post fall . The post fall evaluation is completed to assist in developing interventions to prevent future falls . Implement interventions identified . Record review of, Provider Investigation Report, dated 02/01/2022 revealed Resident #2's injury was reported to Health and Human Services Commission on 01/25/2022 (the written report was submitted on 01/01/2022). The document read in part . Description of the Allegation; Resident was sitting on bed attempting to take off her shirt and slid off the bed and fell between the bed and the nightstand . Description of Injury; Hematoma to left forehead above her eyebrow . Provider response; Resident was assessed on the floor and then put into bed which was in the lowest position . Nightstand was immediately moved to other side of bed. In-service initiated with staff on abuse and falls by LVN A . Record review of, In-Service Training Record, dated 01/17/2022 revealed all facility staff were educated on preventing falls. The document read in part, Preventing Slips, Trips, and Falls in Patient Care Areas and Hallways; We know everyone has completed Slips, Trips, and Falls training however, due to an increase in falls inside and outside our center, we would like to re-visit a few specifics around preventing these types of team-member injuries in our center. Key things to remember in preventing injuries include the following: Make sure equipment, such as wheelchairs, lifts, and bed side tables are properly positioned and are not in the path of travel into and out of the room and bathroom .

Based on observation, interview, and record review, the facility failed to maintain an effective infection prevention and control program designed to provide safe , sanitary and comfortable environment and help prevent the transmission of infections in four of four resident care units (hall 100, 200, 300 and 400) and for one of 8 residents (Resident #1) reviewed for COVID-19 infection control. The facility failed to ensure Resident # 1 who was COVID-19 positive was not left in hall 200 designated for COVID19 negative residents without mask. The facility failed to ensure staff member was screened prior to entering the facility. The facility failed to prevent cross contamination by ensuring laundry staff did not walk through 100 hall designed for COVID19 positive residents to access the laundry. The facility designated halls for COVID19 positive residents ( hall 100, 300 and 400 ) did not have designed areas for doffing/donning PPE to prevent cross contamination. An immediate jeopardy was identified on 06/15/2020 .While the IJ was lowered on 6/26/20, the facility remained out of compliance at a scope of widespread and severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed all facility residents , staff and visitors at risk of contracting COVID-19 infection. Findings include: Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. Perform hand hygiene after removing the respirator or facemask. If reusable respirators (e.g., powered air-purifying respirators (PAPRs)) are used, they must be cleaned and disinfected according to manufacturer ' s reprocessing instructions prior to re-use. Gloves -Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. Gowns -Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's MDS dated [DATE] revealed the resident's BIMS score was 1 of 15 indicating her cognition was severely impaired . The MDS revealed the resident required extensive assistance for bed mobility ,dressing and personal hygiene. She was dependent on staff for transfer, and toilet use. The MDS also indicated the resident was always incontinent of bladder and bowel, and she received [MEDICAL TREATMENT] while a resident in the facility . Record review of Resident #1's care plan revised 6/25/2020 revealed Resident #1 needs [MEDICAL TREATMENT] related to end stage [MEDICAL CONDITION]. Resident will have her face mask on while going to [MEDICAL TREATMENT] and must remove her gown prior to entering the facility . Goal and interventions were outlined : [MEDICAL TREATMENT] days were Tuesday, Thursday, Saturday at DaVita Lonestar. Further review of above care plan indicated it was revised /update after 6/12/2020. Observation and interview on 06/13/2020 at 12.25pm revealed Resident #1 resided in 300 hall designated for COVID19 positive residents. Resident # 1 was picked up by EMS crew who entered the facility using their facility's main entrance and crossed 200 hall (non covid hall ) and entered 300 hall to pick up Resident #1 for [MEDICAL TREATMENT] . Few minutes later , Resident #1 and one of the EMS staff was observed on 200 hall ( non covid hall) where the resident was left on a stretcher by the 200 hall nurses station screaming and moaning with the EMS staff beside her . The resident and the EMS staff waited on 200 hall for about 7 minutes . Resident #1 did not have a mask on, but EMS staff beside Resident #1 had PPE on . EMS staff was asked what they were waiting so, he explained his partner was getting the residents' s [MEDICAL TREATMENT] paper work from facility staff. Resident #1 continued to yell out load and did not answer any questions asked. There was a resident walking around on 200 Hall at this time. All of the doors to the rooms of the resident residing on 200 hall were open. Interview on 06/13/2020 at 12:37pm, LVN #8 who was charge nurses for 200 hall said 200 hall was designed for COVID19 negative residents . LVN#8 said Resident #1 was going to [MEDICAL TREATMENT] and she was brought out from 300 hall which was designed for COVID-19 positive residents. LVN#8 said he did not know why the resident was left in the 200 hall. He proceeded to ask the EMS staff what he was waiting for . Interview on 6/13/2020 at 1:00pm, the DON said all residents on 200 hall were COVID 19 negative . The DON said Resident #1 was positive for COVID19. She confirmed Resident #1 left on 200 hall and transported via hall 200 by EMS staff went to [MEDICAL TREATMENT]. The DON said the EMS crew should not have left Resident #1 on 200 hall .She agreed this placed covid19 negative residents and staff on 200 hall at risk of contracting COVID19. The DON further said EMS crew will now pick up residents using the back exits at the end of the COVID-19 halls to avoid cross contamination and crossing the non- COVID19 . The DON also said the facility had COVID positive residents in the 100, 300 and 400 hall for a total of 91 residents positive. Interview on 6/13/2020 at 1:33pm, LVN #9 Charge Nurse on 300 hall was asked about the facility 's screening for staff , she said she worked last night and was doing a double shift today. LVN #9 was asked how she entered the facility today when she arrived to work, , she said she entered through 300 hall back entrance. She said she was not screened upon entrance and confirmed there was no one to screen staff at that exit. LVN#9 said screening set was the facility's main entrance. She said she came in through the 300 hall exit because she was assigned to work there, and she parked her car at the back , close to the 300 hall exit. Observation on 6/13/2020 at 1:36pm revealed 300 hall had an exit door at the end of the hall. There was no screening set up at this exit. Interview on 06/13/2020 at 1:42pm, the DON said she was not aware that LVN #9 was not screened prior to entering the facility. The DON said the facility had designed screening area at the facility's main entrance. The DON further said 300 hall did not have screening set up at the exit. The DON said Staff should have entered through the main entrance where screening was set up. Observation on 06/13/2020 at 12:35pm revealed the laundry room was at the back of 100 hall. Further observation revealed laundry rooms were accessed from the 100 hall. There were no Isolation waste containers or an area for decontamination on 100 hall, or around the laundry room. Observation and interview on 06/13/2020 at 12:48pm, Laundry Aide #2 said laundry staff entered laundry rooms through the 100-hall designated for COVID19 positive residents. She said staff were screened at the facility's main entrance where they don PPE then walk through the 100 hallway to the laundry. She also said they did not change PPE. They kept on the PPE given to them when they were screened and there was no place for them to dispose of their PPE around the laundry room. Observation on 06/13/2020 between 1:40pm and 1:45pm revealed Hall 300 and 400 did not have cold zones or areas free of contamination. The entire halls were hot zones. PPE doffing stations were at the end of each hall just by the back-exit doors. Staff /visitors who removed their PPE at these locations were still in the hot zones/contaminated area and were exposed to the risk of contracting covid19. There were resident rooms near the hall exits. Interview on 6/15/2020 at 1:53pm, the DON said there were no cold zones on 100, 300 and 400 hall. She said she will work on constructing Cold Zone ( a staging area that is free from contamination) for 100 , 300 and 400 hall. Observation and interview on 6/15/2020 at 1:58pm Housekeeper #1 entered the covid19 positive hall (100) without a gown. He said he entered the hall in search of a gown. He walked passed the donning area in search of a gown. Observation and interview on 6/15/2020 at 2:15pm, Housekeeper #1 was observed on 400 hall. He doffed his gown in a break room then proceeded to walk toward hall exit , passed two rooms occupied by covid19 positive residents with door open before exiting the hall. Housekeeper #1 was asked why he did not have PPE on while in a COVID19 positive hall, he stated he was about to leave the hall , then left . Observation on 06/15/2020 at 2:35pm, halls 300 and 400 did not have cold zones in all covid positive halls . Further observation revealed staff members and visitors who entered the 400-hall using the back door, enter the 400 hall without PPE before they are screened and then provided PPE. 400 Hall is a designated COVID+ hall where staff members and visitors were entering before being donned in PPE which placed them at risk for exposure. Interview on 6/15/2020 at 2:45pm, the DON said the facility had 91 COVID- 19 positive residents and there were 21 COVID 19 negative residents residing on hall 200 . Record review of facility's policy on COVID-19 education, prevention and response guide dated June 2020 revealed following the recommendation from CDC and CMS , the facility will actively screen for cough, shortness of breath , or at least two of the following : fever, chills, repeated shaking with chills , muscle pain, headache , sore throat and new loss of smell. All individuals permitted entry to the center are required to adhere to the preventions and precautions in place to ensure the safety and well-being of our patients, residents and team members. Upon entry , all individual must wash hands or use alcohol-based sanitizer .All visitor must wear required PPE while in the building . Record review of the Policy on Infection Control dated 10/2014 revealed in part: A successful infection control program must have administrative collaboration, resources, and an organizational dedication to a cultural commitment of quality and safety. The primary objective of infection control is to eliminate healthcare associated infections, which adds to the burden of healthcare overall. Beyond the added morbidity for the individual patient/resident, healthcare associated infections lead to a tremendous financial burden to both the center and the individual patient/resident . the four major components of an infection control program must include: 1. Standard precautions, including hand hygiene 2. Isolation precautions 3. Environmental cleaning 4. Surveillance. Standard Precautions are the recommended practice for the care of all patients and residents receiving care within our centers. When properly followed and adhered to, they reduce the risk of transmission of infectious agents between patient/resident and team member even when the presence of an infectious agent is unknown or not apparent. Standard precautions apply whenever there is potential for contact with blood, bodily fluids, non-intact skin, mucous membranes, and secretions with the exception of perspiration. Standard precautions include: 1. Hand Hygiene before and after patient/resident contact -including after gloves are removed. 2. The use of personal protective equipment (PPE)-i.e. gloves, gowns and eye protection in situations where exposure is likely. 3. Safe disposal of sharps and other biomedical waste, such as the placement of soiled linens in impervious bags . Droplet precautions are initiated for microorganisms expelled in respiratory secretions that are larger than 5 micron. Droplets remain suspended in the air for limited periods of time .Contact precautions should also be implemented with droplet precautions as many of these organisms can be spread not only by droplets but via direct patient/resident contact . On 06/15/2020 at 3:00pm, the facility interim Administrator , the DON and the facility Medical Director were informed Immediate jeopardy was identified based on above failures. Immediate jeopardy template was emailed to the facility interim Administrator and the DON. They acknowledged receipt of template and a plan of immediate jeopardy removal was requested to be submitted . A Plan of Removal was submitted by the Administrator on June 15, 2020. After several revisions, the final Plan of Removal was accepted on 6/18/20 at 8:42am. Plan of Removal for Immediate Jeopardy 83 positive COVID-19 tests in the Center 55 positive team members Station 2 is the negative patient unit. Team members and essential visitors will be screened before entering Station 2. The screening will take place at the front entrance by the Station 2 nurse and then the nurse will be replaced by an administrative team member. Hand hygiene will be performed and PPE will be donned before entering the unit. The team members were trained by the DCE on 6-15-20. The completed screening sheets will be maintained in a binder and in the administrator's office. DNS or designee will validate daily with the schedule to the screening sheet that the team members have been screened. Stations 1, 3 and 4, are the positive units. Outside entrances established on Unit 4 to access Unit 3 and 4 & Unit 1 to access only Unit 1. The outside entrance will be the entrance and exit for team members caring for positive residents. These team members and essential visitors will be screened upon entry. The screening will occur at the doorway in the Cold zone. Team members will then perform hand hygiene and don their PPE. This practice of donning in the Cold zone began on 6-15-20. The completed screening sheets will be maintained in the Administrator's office. The first team member to arrive for laundry will be screened at Station 4 and then return to the laundry area. That team member will then screen all the other housekeepers and laundry. The laundry area will also contain the necessary items to screen the team members who work in the laundry area. These areas will contain the screening form, thermometer, and sanitizer, and team members entering here will be screened. When laundry deliveries and picks up laundry it will be placed outside each entrance and the laundry will not pass through the negative unit. This training for laundry was provided on 6-15-20 by the Director of Clinical Education. The DNS or designee will validate from the schedule to the screening sheet that each team member has been screened before entering to work. The center has an entrance for screening at Station 4, the Front lobby, Station 1 and also the laundry area. Residents that go to [MEDICAL TREATMENT] will be provided a surgical mask to have on when they leave the center with transport. The [MEDICAL TREATMENT] centers are aware of each residents Covid 19 status. Test results were sent to the [MEDICAL TREATMENT] centers as they requested. When the residents return from [MEDICAL TREATMENT], they are assisted with changing clothes and basic hygiene cleaning, and provided with a new mask as needed. This practice has been conducted since the guidance was initiated in April 2020 and continues today. The Center is not accepting any new residents and that includes [MEDICAL TREATMENT] residents. All [MEDICAL TREATMENT] residents have been tested with the exception of one, who refuses and the Center considers him to be positive. He is on a positive unit Positive residents will leave through the appropriate exit on their designated care area to avoid going through the negative hall. So if the resident resides on Station 4 or 3, they will leave from the back through the exit of unit 4. If the resident residents on Station 1 they will leave from the designated exit on Station 1. If the resident resides on Station 2 they will exit from the entrance of the building. Team members were educated on this process on 6-15-20 by the Director of Clinical Education. Signs have been placed on the Front doors to designate were to pick up the residents. The screener at the front door will also assist in were to send the drivers for pick up. The DNS did inform the company we contract with regarding this information by phone on 6-15-20. Signs were placed at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. This training was started on 6-15-20 by the Director of Clinical Education and will continue until all team members have been educated. At the entrance to station 1 and 4, the center has implemented a clean area, anteroom, dedicated with a plastic Barrier. This anteroom will establish a clean area to be able to exit the center after doffing and performing hand hygiene without going back through positive areas. Team member education began on 6-15-20 by the Director of Education and will be ongoing until all team members have been educated. Areas were clearly marked by signage to designate as positive or negative areas on 6-15-20 to designate not to enter the negative unit through the smoke doors. To enter the negative, you must be screened at the front door by the designated team member. Team members were educated regarding screening at the doors before entry into the center and the correct entrance to use based upon which population of patients they care for. This training was started on 6-15-20 by the Director of Clinical Education and will be ongoing until all team members have been educated. Center spoke to dispatch of ambulance service to instruct them at which entry they need to go through to pick up the resident. The team members will assist the resident upon leaving their room to don surgical mask for transport. Team members were educated regarding the flow of traffic from negative area to positive areas. This education was provided on 6-15-20 by the Director of Clinical Education and will be ongoing until all team members have been educated. Team members were educated regarding donning and doffing when entering and exiting the center at the designated areas. This includes dietary, housekeeping, laundry, nursing, therapy, and administrative team members. New team members are transferred on to the matrix and education will be provided to all team members as required. Regardless if the team member is new or established, they will not be allowed to work until all the education is completed as needed. Laundry and Housekeeping follow their policy and procedure for cleaning and disinfecting with the appropriate approved chemicals for cleaning. They have been educated by according to the policy. This education was provided on 6-15-20 by the Director of Clinical Education. Dietary has been educated on the appropriate cleaners and chemicals to use in their departments. This education was provided on 6-15-20 by the Director of Clinical Education. DNS or designee will monitor daily every shift until verification that staff screening is being performed at each entrance to ensure team members and essential visitors are being monitored. This process will continue until successful validation. DNS or designee will audit that residents that are leaving the center have the appropriate mask on and are leaving through the appropriate exit in the center. The order for a mask for [MEDICAL TREATMENT] residents that leave the center has been added to the electronic medication administration record. The nurse is to document that the mask was provided before the resident left the center. DNS will validate by auditing the EMR for completion. Administrator or designee will audit entrances and exits to units to ensure the correct flow of traffic. DNS or designee will audit each shift that donning and doffing are being performed appropriately with team members and essential visitors. Audit information will become a part of monthly QAPI for continued monitoring and evaluation. Once it has been determined that enhanced system interventions and monitoring has been made, the frequency of the auditing process will be determined. The center has added this Removal Plan to the Covid 19 emergency plan. The center is not admitting new residents at this time. The only residents the center is accepting in the center are our residents returning from the hospital. Depending on their Covid 19 status they will be placed in observation in the appropriate unit. After the initial training for the team members a pretest regarding Handwashing/Hand Hygiene, Alcohol-Based Hand Rub, Personal Protective Equipment, and Droplet Precautions will be given. Then team members will conduct the Posttests and skill validations. Residents may be released from isolation or the Covid-19 unit based upon CDC guidance: Asymptomatic Residents with suspected or confirmed COVID-19 may be released from isolation or the COVID-19 positive unit when: o At least 10 days* since the onset of symptoms o No fever for 3 full days (off of fever-reducing medications) o Improving symptoms (this does not mean the symptoms are gone) B. Residents with laboratory confirmed COVID-19 who have not had any symptoms may be released from isolation or the COVID-19 positive unit when: o Time-based strategy. 10 days* have passed since the date of their first positive COVID-19 diagnostic test assuming they have not subsequently developed symptoms since their positive test. If they develop symptoms, then the symptom-based or test-based strategy should be used. The Center already has a negative unit to move recovered patients too. The surveyor monitored the POR and included the following: Observation on 06/16/20 at 12:15 PM revealed screening at front entrance of facility. Signs are posted at front of the building restricting access to building related to COVID-19 and directing transportation to designated resident pick up sections. Observation on 06/16/20 at 12:36 PM revealed 200 hallway was designated for COVID-19 negative residents. No concerns noted related to Infection Control. Residents wearing mask when outside of bedroom. Signs at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. Observation on 06/16/20 at 12:38 PM revealed 300 hallway was designated for COVID-19 positive residents. Staff passing out lunch disposable dinnerware on carts. Signs at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. Residents wearing mask when outside of bedroom. Observation on 06/16/20 at 12:40 PM revealed 400 hallway was designated for COVID-19 positive residents. Staff wearing PPE on the unit, screening in place, plastic with zipper to separate cold zone area from unit. Near cold zone is room to dispose of PPE which goes to bathroom to wash hands and leave thru the cold zone. Signs at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. Observation on 06/16/20 at 12:43 PM revealed 100 hallway was designated for COVID-19 positive residents. Plastic with zipper to separate cold zone area from unit. Near cold zone is room to dispose of PPE which goes to bathroom to wash hands and leave thru the cold zone. Signs at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. Residents wearing mask when outside of bedroom. Housekeeper #1 on the unit without face mask or face shield. In an interview on 06/16/20 at 12:45 PM Operations Support & the DON stated the facility set up cold zone areas for screening, PPE, and exit/enter the building. The laundry comes through the back door, it is not mixed with the negative residents. The negative residents get their clothes through the entrance and it does not go through the hallway with positive residents. Observation on 06/17/20 at 10:40 AM revealed screening at front entrance of facility. Signs are posted at front of the building restricting access to building related to COVID-19. Signs at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. Therapy Staff being screened at front entrance, donning PPE before entering unit, and sanitizing. In an interview on 06/17/20 at 10:45 AM Operations Support stated the facility was in the process of deep cleaning, they were moving residents around, moving beds so everything could be cleaned up. The facility was changing the water pitchers and replacing with disposable ones which can be changed out at night. The meals are put on disposable trays and left at the door of positive hallways. The dinner carts are taken out the back and sanitized with bleach. Observation on 06/17/20 at 10:46 AM revealed MA #1 was not wearing face shield on the 100 hallway. Observation on 06/17/20 at 10:51 AM revealed Housekeeper #2 was on the positive 400 hallway without a gown on. In an interview on 06/17/20 at 10:55 AM Operations Support stated the Housekeeper #1 was suspended for not having mask on face. His supervisor spoke with him yesterday. Observation on 06/17/20 at 10:57 AM revealed RN#1 on 400 hallway without face shield. Her mask not secured on face, one strap holding mask on face from rear. In an interview on 06/17/20 at 11:00 AM Operations Support stated the RN#1 was the treatment nurse and does not like to wear face shield because she had glasses and the face shield fogged up. Observation on 06/17/20 at 11:05 AM revealed ambulance at the rear of station 400 hallway for pickup of a resident for an appointment in designated area. Observation on 06/18/20 at 12:00 PM revealed screening at front entrance of facility. Signs are posted at front of the building restricting access to building related to COVID-19. Signs at smoke barrier doors to alert and redirect team members to prevent cross contamination from a positive to negative hall. Staff being screened at front entrance, donning PPE before entering unit, and sanitized. In an interview on 06/18/20 at 12:04 PM Operations Support stated the facility had three cold zones with plastic and zippers for the 100 hallway, the 400 hallway, and entrance into the facility. Each area has screening stations set up. Laundry also had a screening area. In an interview on 06/18/20 at 12:06 PM the Dietary Manager stated dietary staff are trained to deliver the food to the doors of the positive hallways. They knock on the door to let them know the food is outside. The food is delivered in carts and the residents eat off disposable trays and utensils. The tray and the utensils are disposed of in trash. The staff on the unit take the carts outside thru the back of the facility and they carts are sprayed with a bleach cleaner for sanitation. In an interview on 06/18/20 at 12:09 PM the Cook stated dietary staff deliver the food carts to the door of the positive units. The nurse gets the cart and they pass out the trays to residents. Food is served on disposable trays and utensils. The carts are brought to the back where they are sanitized with a cleaner. Observation on 06/18/20 at 12:11 PM revealed no concerns on the 100 hallway. Staff were in proper PPE, cold zone set up for screening, PPE supplies available, and hand sanitizer available. Observation on 06/18/20 at 12:16 PM revealed no concerns on the 400 hallway. Staff were in proper PPE, cold zone set up for screening, PPE supplies available, and hand sanitizer available. In an interview on 06/18/20 at 12:21 PM the Activity Coordinator stated she was trained on screening employees and essential personnel. If someone had a temperature above 98.6 then they would not be allowed to enter the facility. Staff are to put on a face shield, mask, gown and sanitize before entering to the 400 hallway. Before reentering the cold zone area staff are to remove gown and dispose in biohazard, wash hands leave through the cold zone. Observation on 06/18/20 at 12:24 PM on 300 hallway revealed staff were wearing proper PPE. Observation on 06/18/20 at 12:30 PM revealed signs throughout the facility regarding: COVID-19, PPE, signs and symptoms, areas to enter/exit the building. Observation on 06/18/20 at 12:35 PM revealed lunch was delivered to the 400 hallway. The staff passing out food trays on to residents which were disposable . Observation on 06/18/20 at 12:40 PM in the Laundry Room revealed there was a screening area set up, PPE was available, thermometer, and screening forms. The Laundry Aide was washing clothes, she was wearing mask, and face shield. In an interview on 06/18/20 at 12:40 PM Housekeeping Supervisor stated clothes are picked up on the units and taken through the back door, when the dirty clothes arrive staff have to put on a gown in the dirty area and wash positive resident clothes separate from negative resident's clothes. Once the clothes are inside washer the staff will take off the gown and sanitize. Once the clothes are dried they are bagged up and taken to the units. The 100, 300, and 400 hallways are given their clothes through the screening area, 200 hallway's clothes goes through the front entrance which is for the negative side. In an interview on 06/18/20 at 12:46 PM District Manager #1 stated the facility used Virex II 256, Vital Oxide, and Quick Care Disinfectant to spray rooms, clean floors, or spray areas in the building. In an interview on 06/18/20 at 12:52 PM Admissions Coordinator stated she was trained to screen employees and essential personnel at the entrance of the building. She takes temperatures and if the temperature is over 99 degrees then they are not permitted to enter. She makes sure everyone has PPE when they enter the unit and sanitizes hands. When someone leaves the areas the dispose of PPE in biohazard bins and sanitize. She directed transportation to the various units to pick up positive residents in the rear of the facility. Only negative residents were designated to come to through the front entrance. Observation on 06/18/20 at 12:53 PM revealed signs on the front door directing transportation to unit 100 and 400 for resident pick up. In an interview on 06/18/20 at 1:05 PM Housekeeper #2 stated staff are supposed to sanitize, put on gown, gloves, mask, and face shield when entering a unit. When it was time to exit the unit she disposed of gown and sanitized hands. The staff also sanitized between rooms on the positive unit. The trash is gathered and placed in bins. Trash is taken out of the back of the unit. Housekeeping staff used Virex II 256 to clean floors and wipe down surfaces. In an interv (TRUNCATED)

Based on observation, interview, and record review, the facility failed to consult with the resident's physician regarding a change in condition and there was a need to alter treatment for one of ten residents (CR#1) reviewed for notification of changes. The facility did not consult with CR#1 physician after learning a diagnostic exam could not be completed for three days. She was admitted to the hospital with [REDACTED]. This failure affected one former resident, causing a decline in health and placed all residents at risk of harm, injury, and hospitalization . Findings were: Record review of CR#1's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], hypertension and [MEDICAL CONDITION]. CR#1 was discharged on [DATE]. Record review of CR#1's Care Plan dated 09/04/15 revealed CR#1 was at risk for experiencing occasional pain related to [MEDICAL CONDITION]. Staff are to evaluate CR#1's pain daily using 1-10 scale, observe pain symptoms and report to physician. CR#1 was at risk for [MEDICAL CONDITION], abnormal labs, related to [MEDICAL CONDITION]. Staff are to assess skin abnormalities, order labs and x-rays per physician orders, with an onset date of 09/19/15 and target date of 10/15/19. CR#1 has risk for pressure ulcers related to decreased mobility. Staff are to complete a full skin evaluation weekly. CR#1 needs daily observation of skin with routine care with an onset date of 09/19/15 and target date of 10/15/19. Record review of CR#1's MDS dated [DATE] revealed she had a BIMS of 4, indicating severe cognitive impairment. She required supervision for walking and locomotion on and off the unit. She received PRN pain medications and had occasional pain that did not affect day-to-day activities. The pain intensity was rated at '4' on a scale of 1-10. She was at risk of developing pressure ulcers but did not have any skin issues. Record review of CR #1's Progress Notes dated 7/4/19 at 2:10pm written by LVN G revealed CR #1 complained of pain to her 1st and 2nd toes of her right foot. The Physician was notified and an x-ray was ordered. Record review of a Radiology Report dated 7/5/19 revealed CR #1 had no visible fractures in her right foot. The Physician signed/acknowledged the report on 7/12/19. Record review of CR#1's Physician Orders dated 07/2019 revealed .Monitor for bleeding or bruising every shift . Monitor for pain and discomfort every shift . Both orders had a start date of 03/20/19. Further review of the physician's orders revealed an order for [REDACTED]. 2 Record review of CR #1's MAR indicated [REDACTED] - 7/4/19 at 11:29am with a pain level of 7 on a scale of 1-10 - 7/6/19 at 8:35am with a pain level of 5 on a scale of 1-10 - 7/6/19 at 4:52pm with a pain level of 5 on a scale of 1-10 - 7/7/19 at 3:24pm with a pain level of 5 on a scale of 1-10 - 7/8/19 at 11:39pm with a pain level of 7 on a scale of 1-10 - 7/11/19 at 12:33pm with a pain level of 5 on a scale of 1-10 - 7/15/19 at 10:22am with a pain level of 6 on a scale of 1-10 - 7/18/19 at 11:10am with a pain level of 6 on a scale of 1-10 - 7/21/19 at 10:47am with a pain level of 5 on a scale of 1-10 - 7/21/19 at 3:55pm with a pain level of 6 on a scale of 1-10 Record review of CR #1's Nursing Progress Notes revealed follow-up pain assessments after Tylenol 325mg was administered as needed on the dates above. The medication was noted to be effective with decreased pain. Record review of CR #1's MAR indicated [REDACTED]. Record review of skin assessments dated 7/5/19 and 7/19/19 revealed CR #1's skin was intact and dry. The skin assessments were completed by LVN G. Record review of CR#1's vital pain scale revealed: 7/26/2019 1:30pm- Pain level of 4, on a scale of 1-10 7/26/2019 7:19pm- Pain level of 4, on a scale of 1-10 7/27/2019 10:27am- Pain level of 5, on a scale of 1-10 7/28/2019 12:28pm- Pain level of 6, on a scale of 1-10 7/29/2019 6:06pm- Pain level of 4, on a scale of 1-10 Record review of CR#1's Weekly Skin Review dated 07/26/19 revealed she had discoloration noted to four toes on right foot. Record review of CR#1's Progress Notes dated 07/26/19 at 1:27pm written by LVN A revealed .Weekly Nurses Note Summary: Resident in bed responds to verbal stimuli respiration even non labored breathing skin assessment complete noted discoloration to four of her toes on right foot notified NP received new order for arterial Doppler to right foot resident refused shower c/o of pain to foot medicated for pain in bed ADL care given as needed call light within reach will continue to monitor . Record review of CR#1's Progress Notes dated 07/27/19 at 10:18pm written by LVN B revealed General Note Note Text: Called Mobilex twice concerning the Arterial Doppler ( Confirmation # 604) of right foot ordered for the resident, spoke to a staff who said that due to the high volume of orders, resident is scheduled for Monday 07/29/2019 . Record review of CR#1's Progress Notes dated 07/29/19 at 4:56pm written by the ADON revealed General Note Note Text: Received call from Attending NP inquiring about status of ordered arterial doppler to left foot. Doppler was performed today but results were not available at this time per mobilex. Order given to send resident to (Local Hospital) to evaluate discoloration and pain to left foot. NP voiced attempt call to R/P to discuss new order, call unsuccessful. Writer placed call to R/P and second contact to make notification of order to transfer and to see if there was a hospital preference both calls unsuccessful @ this time . Record review of CR#1's Progress Notes dated 07/29/19 - 7:23pm revealed .General Note Note Text: resident aaox1, was transferred to (Local Hospital) for evaluation by (EMS) on wheel chair assisted by 1 EMS staff, skin intact, warm dry to touch, respiration even unlabored, abdomen round non distended, she ate dinner 100% before leaving, all 4pm medications administered, resident is changed by assigned staff, she is able to verbalize needs, no complain of pain, no distress or discomfort noted, vs bp 133/64, p 71, t 98.0, r 15 . Record review of CR#1's hospital records dated 07/29/19 revealed .MS Ankle/Foot Text/Dict Note: interdigital dark, purulent drainage between 3rd and 4th toes. Hyperpigmentation of dorsal right toes 2-4 with exquisite tenderness to palpitation. No visible deformities. Limited toes 2-4 ROM due to pain. No crepitus appreciated. Mild [DIAGNOSES REDACTED] extends from hyperpigmented areas to midfoot. No lacerations or open wounds appreciated Radiology - XR Foot 3 Impression: No soft tissue [MEDICAL CONDITION] or osseous erosive changes. Age-indeterminate articular extending fracture in the base of the 2nd proximal phalanx .Clinical Impression Primary Impression: Gangrene of right foot. Secondary Impressions: Closed fracture of phalanx of right second toe, Lactic acidemia, Wet gangrene .Chief Complaint: Right foot pain for more than 2 weeks . The records dated 7/29/19 to 7/31/19 did not indicate that CR #1 had any type of surgery. Record review of CR#1's Radiology Report dated 07/29/19 revealed Conclusion: Occluded posterior tibial artery (an obstruction to an artery that runs down the back of the leg). Continuous monophasic waveforms throughout compatible with multifocal hemodynamically significant stenosis. The presence of these waveforms in the CFA may reflect inflow disease in the pelvis (Pelvic inflow disease is a type of peripheral artery disease that affects arteries in the legs that supply blood to the lower half of the body.) The report was signed by the physician on 7/31/19 at 7:49pm. In a telephone interview on 08/24/19 at 10:56 AM the Family Member stated CR#1 was currently at the hospital in ICU. Family Member stated CR#1 had complained of pain and the facility did not address the issue, and told her CR #1 had dementia and was confused. Family Member said CR #1 had her toes amputated in the middle of (MONTH) this year. In an interview on 08/24/19 at 11:56 AM the ADON stated LVN A was completing a weekly skin assessment and noticed four of her toes were darkened on 07/26/19. The physician was notified and an arterial doppler was ordered on [DATE]. She said the NP called on Monday 07/29/19 and asked about the results. She said the results were not available, so the NP ordered CR#1 to be sent to the hospital, and said the NP did not want to wait that long for results. She said the arterial doppler was performed on Monday, 07/29/19. She said on Saturday, 7/27/19, LVN B did call Mobilex regarding arterial doppler to see when they could come to the facility. She said the order was not stat (immediately) and Mobilex said they were backed up and would come as soon as they were able. In an interview on 08/24/19 at 12:11 PM LVN B stated she was expecting a call from Mobilex to confirm CR #1's visit. She called them twice on 07/27/19 to find out when they would come. She said Mobilex told her they had a large volume of work and would make it to the facility on Monday. She said because CR #1's pain did not increase, and the color of her toes did not change more than it was, she did not call physician. She said she put in a note that she called Mobilex and got a confirmation number for doppler. She said she gave the oncoming nurse the information. She said the order was not a 'stat order' and said maybe if it was she would have pushed harder. She said she did not call physician because it was not a STAT order and CR#1's condition did not get worse. In an interview on 08/24/19 at 12:42 PM CNA C stated CR#1 reported pain in her feet, so she notified the nurse. She said CR#1 complained of pain a couple of weeks before she went to the hospital. She said CR #1 would always say her foot hurts, so CNA C would let the nurse know. She said the aides gave CR#1 showers and her toe nails would be long but that was about it. She said if the aides saw any discoloration the aides would notify the nurse. In an interview on 08/24/19 at 12:52 PM CNA D stated she was not aware that CR#1 had to be sent to hospital due to issues with foot. She said CR#1 would complain about pain in her feet, so she notified the nurse. She said CR#1 had pain for two days and the nurse contacted the physician. She said CR#1 went to the hospital on her day off. Observation and interview on 08/24/19 at 1:25 PM in the hospital revealed CR#1 was lying in bed, dressed in a gown, on contact isolation, receiving IV antibiotics and O2 therapy. Resident was confused and could not remember how long she had been at the hospital. She stated her foot had been hurting for months, the facility gave her Tylenol for the pain. CR#1 could not explain exactly when the pain began. Record review of in-service documentation dated 08/27/19 revealed a facility in-service was completed on 08/27/19 regarding change of condition; SBAR documentation for change of condition, documentation of problem and timely solution, notification of Physician/NP/Responsible Party with any change of condition, documentation in 24 hour report book with interventions plus notifications, and notification of ADON for station. In-service had 20 nurse signatures. In an interview on 09/05/19 at 3:29 PM the NP stated she saw CR#1 a few days before she received the call regarding the resident's toes. She said she was receiving Tylenol PRN which was working. She said the resident complained of pain and she wanted it more often to help with pain so she had the order changed to scheduled. She received a call on Friday (07/26/19) regarding the resident's discolored toes, and the toes were cool to touch. She said she ordered the arterial doppler to be done. She said she did not receive a call from the facility regarding the arterial doppler not being able to be performed until Monday. She said the order was not 'stat' so she did not follow up within a few hours or monitor like she would have for a stat order. She said she called the facility on Monday to get the results from the doppler and it had just been completed. She said she did not want to wait for Mobilex to read the results, so she spoke with the physician and had them send the resident out to hospital. In an interview on 09/06/19 at 10:29 AM RN [NAME] stated if a laboratory/diagnostic order was 'stat' Mobilex would come that day. She said if the order was routine, Mobilex would come the same day or the following day. She said if Mobilex could not come the following day she would call the physician to let them know what is going on and get further instructions. She said the nurse would assess the resident and give the physician the findings of the assessment. She said the physician will make the decision to send the resident out or to continue to monitor the resident. In an interview on 09/06/19 at 11:10 AM MA F stated CR#1 had been in pain for a few weeks, and sometimes she could not get up. She said she reported the pain to the nurse. Sometimes CR#1 would not walk due to foot pain. She said one day, CR#1's foot was hurting and she sat down in middle of the hallway. She reported the pain to the nurse, so they would give PRN pain medications. In an interview on 09/06/19 at 11:21 AM LVN G stated sometimes CR#1 would not want to get up from her bed, and she would complain of leg, hand, and foot, pain. In an interview on 09/06/19 at 11:34 AM the DON stated depending on the acuity of the resident, if a resident was stable, and there was no change of condition, the facility would not call the physician to follow up on lab work. She said if the lab work was not scheduled 'stat' then they did not do them right away. She said the arterial doppler was usually a scheduled routine exam. She said Mobilex will let them know when they can make it to the facility. In an interview on 09/06/19 at 12:04 PM the LVN H stated Mobilex usually comes the same day for a stat order and the next day for a routine order. If they do not come within that time frame they will call the physician to get further instructions what to do because the resident may need to be sent out. She said she had not had any problems with them taking more than a day to get labs or diagnostics. In an interview on 09/06/19 at 1:23 PM MA J stated CR#1's her pain level was 5 and 6 on the weekend of 7/27/19, she gave CR#1 scheduled pain medications. She was not sure about PRN pain medications. When she gave the resident medications CR#1 stated she had a pain level of 5 and a pain level of 6. She reported this to the nurse about pain level, she was not sure what nurse did about the pain. In an interview on 09/06/19 at 1:50 PM the DON stated in her opinion CR#1 was given adequate care and there was no need to call the physician. The process of the toes having to be amputated was not an immediate issue and took time to happen. In an interview on 09/20/19 at 1:41 PM, LVN A stated she went to do skin assessment on CR#1 and noticed her toes were discolored. She notified the NP who ordered an Arterial Doppler sometime after 1:00 PM. She notified the family of the situation and contacted Mobilex. She received a confirmation number and advised the oncoming about the resident's status. In an interview on 09/20/19 at 2:15 PM the DON stated the facility completed an in-service on 08/27/19 regarding change of condition, SBAR, proper documentation, and notifications. The facility completed monthly in-services also on change of condition to continually educate the staff. The facility reviewed orders and they don't have any outstanding lab work that needed to be completed. In an interview on 09/20/19 at 2:49 PM the DON stated CR#1 did not have a STAT order. The arterial doppler test was not expected to be completed on Friday 07/26/19. She said if there would have been a change in condition for CR#1 the expectation would have been for the nurse to contact the physician. She said CR#1's condition did not change. She said if the order would have been lab work or chest x-ray the order would have been STAT. She said when CR #1 left the facility, it took 2-3 weeks before her toes were amputated. She said sometimes after residents leave the facility their condition worsens. Record review of the facility policy Notification of Change in Patient/Resident Health Status dated (MONTH) (YEAR) revealed Purpose .To Ensure all interested parties are informed of the patient's/resident's change in health status so that a treatment plan can be developed which is in the best interest of the patient/resident Process .The center will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the patient representative when there is: (B) Acute illness or a significant change in the resident's physical, mental, or psychosocial status. Notification will be immediate. (I.e. Life threatening conditions are such things as a [MEDICAL CONDITION] or stroke. Clinical complications are such things as development of a new pressure injury, onset or recurrent periods of [MEDICAL CONDITION], recurrent urinary tract infection, or persistent decline in psycho social status) (C) A need to alter treatment significantly (i.e a need to discontinue an existing form of treatment). Depending on the nursing assessment appropriate notification may be immediate to 48 hours .Nursing judgement is an integral part of the skilled care provided in this center, therefore, such judgement must be applied in a case by case basis in keeping with acceptable nursing practice .

Based on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of ten residents (CR#1) reviewed for quality of care. The facility failed to assess CR #1 when she had signs of foot pain for 3 weeks. She was admitted to the hospital with [REDACTED]. This failure affected one former resident, causing a decline in health and placed all residents at risk of harm, injury, and hospitalization . Findings were: Record review of CR#1's face sheet revealed she was an [AGE] year old female that was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]., [MEDICAL CONDITIONS], hypertension and [MEDICAL CONDITION]. CR#1 was discharged on [DATE]. Record review of CR#1's Care Plan dated 09/04/15 revealed CR#1 was at risk for experiencing occasional pain related to [MEDICAL CONDITION]. Staff are to evaluate CR#1's pain daily using 1-10 scale, observe pain symptoms and report to physician. CR#1 was at risk for [MEDICAL CONDITION], abnormal labs, related to [MEDICAL CONDITION]. Staff are to assess skin abnormalities, order labs and x-rays per physician orders, with an onset date of 09/19/15 and target date of 10/15/19. CR#1 has risk for pressure ulcers related to decreased mobility. Staff are to complete a full skin evaluation weekly. CR#1 needs daily observation of skin with routine care with an onset date of 09/19/15 and target date of 10/15/19. Record review of CR#1's MDS dated [DATE] revealed she had a BIMS of 4, indicating severe cognitive impairment. She required supervision for walking and locomotion on and off the unit. She received PRN pain medications and had occasional pain that did not affect day-to-day activities. The pain intensity was rated at '4' on a scale of 1-10. She was at risk of developing pressure ulcers but did not have any skin issues. Record review of CR #1's Progress Notes dated 7/4/19 at 2:10pm written by LVN G revealed CR #1 complained of pain to her 1st and 2nd toes of her right foot. The Physician was notified and an x-ray was ordered. Record review of a Radiology Report dated 7/5/19 revealed CR #1 had no visible fractures in her right foot. The Physician signed/acknowledged the report on 7/12/19. Record review of CR#1's Physician order [REDACTED].Monitor for bleeding or bruising every shift . Monitor for pain and discomfort every shift . Both orders had a start date of 03/20/19. Further review of the physician's orders [REDACTED]. 2 Record review of CR #1's MAR indicated [REDACTED] - 7/4/19 at 11:29am with a pain level of 7 on a scale of 1-10 - 7/6/19 at 8:35am with a pain level of 5 on a scale of 1-10 - 7/6/19 at 4:52pm with a pain level of 5 on a scale of 1-10 - 7/7/19 at 3:24pm with a pain level of 5 on a scale of 1-10 - 7/8/19 at 11:39pm with a pain level of 7 on a scale of 1-10 - 7/11/19 at 12:33pm with a pain level of 5 on a scale of 1-10 - 7/15/19 at 10:22am with a pain level of 6 on a scale of 1-10 - 7/18/19 at 11:10am with a pain level of 6 on a scale of 1-10 - 7/21/19 at 10:47am with a pain level of 5 on a scale of 1-10 - 7/21/19 at 3:55pm with a pain level of 6 on a scale of 1-10 Record review of CR #1's Nursing Progress Notes revealed follow-up pain assessments after Tylenol 325mg was administered as needed on the dates above. The medication was noted to be effective with decreased pain. Record review of CR #1's MAR indicated [REDACTED]. Record review of skin assessments dated 7/5/19 and 7/19/19 revealed CR #1's skin was intact and dry. The skin assessments were completed by LVN G. Record review of CR#1's vital pain scale revealed: 7/26/2019 1:30pm- Pain level of 4, on a scale of 1-10 7/26/2019 7:19pm- Pain level of 4, on a scale of 1-10 7/27/2019 10:27am- Pain level of 5, on a scale of 1-10 7/28/2019 12:28pm- Pain level of 6, on a scale of 1-10 7/29/2019 6:06pm- Pain level of 4, on a scale of 1-10 Record review of CR#1's Weekly Skin Review dated 07/26/19 revealed she had discoloration noted to four toes on right foot. Record review of CR#1's Progress Notes dated 07/26/19 at 1:27pm written by LVN A revealed .Weekly Nurses Note Summary: Resident in bed responds to verbal stimuli respiration even non labored breathing skin assessment complete noted discoloration to four of her toes on right foot notified NP received new order for arterial Doppler to right foot resident refused shower c/o of pain to foot medicated for pain in bed ADL care given as needed call light within reach will continue to monitor . Record review of CR#1's Progress Notes dated 07/27/19 at 10:18pm written by LVN B revealed General Note Note Text: Called Mobilex twice concerning the Arterial Doppler ( Confirmation # 604) of right foot ordered for the resident, spoke to a staff who said that due to the high volume of orders, resident is scheduled for Monday 07/29/2019 . Record review of CR#1's Progress Notes dated 07/29/19 at 4:56pm written by the ADON revealed General Note Note Text: Received call from Attending NP inquiring about status of ordered arterial doppler to left foot. Doppler was performed today but results were not available at this time per mobilex. Order given to send resident to (Local Hospital) to evaluate discoloration and pain to left foot. NP voiced attempt call to R/P to discuss new order, call unsuccessful. Writer placed call to R/P and second contact to make notification of order to transfer and to see if there was a hospital preference both calls unsuccessful @ this time . Record review of CR#1's Progress Notes dated 07/29/19 - 7:23pm revealed .General Note Note Text: resident aaox1, was transferred to (Local Hospital) for evaluation by (EMS) on wheel chair assisted by 1 EMS staff, skin intact, warm dry to touch, respiration even unlabored, abdomen round non distended, she ate dinner 100% before leaving, all 4pm medications administered, resident is changed by assigned staff, she is able to verbalize needs, no complain of pain, no distress or discomfort noted, vs bp 133/64, p 71, t 98.0, r 15 . Record review of CR#1's hospital records dated 07/29/19 revealed .MS Ankle/Foot Text/Dict Note: interdigital dark, purulent drainage between 3rd and 4th toes. Hyperpigmentation of dorsal right toes 2-4 with exquisite tenderness to palpitation. No visible deformities. Limited toes 2-4 ROM due to pain. No crepitus appreciated. Mild [DIAGNOSES REDACTED] extends from hyperpigmented areas to midfoot. No lacerations or open wounds appreciated Radiology - XR Foot 3 Impression: No soft tissue [MEDICAL CONDITION] or osseous erosive changes. Age-indeterminate articular extending fracture in the base of the 2nd proximal phalanx .Clinical Impression Primary Impression: Gangrene of right foot. Secondary Impressions: Closed fracture of phalanx of right second toe, Lactic acidemia, Wet gangrene .Chief Complaint: Right foot pain for more than 2 weeks . The records dated 7/29/19 to 7/31/19 did not indicate that CR #1 had any type of surgery. Record review of CR#1's Radiology Report dated 07/29/19 revealed Conclusion: Occluded posterior tibial artery (an obstruction to an artery that runs down the back of the leg). Continuous monophasic waveforms throughout compatible with multifocal hemodynamically significant stenosis. The presence of these waveforms in the CFA may reflect inflow disease in the pelvis (Pelvic inflow disease is a type of peripheral artery disease that affects arteries in the legs that supply blood to the lower half of the body.) The report was signed by the physician on 7/31/19 at 7:49pm. In a telephone interview on 08/24/19 at 10:56 AM the Family Member stated CR#1 was currently at the hospital in ICU. Family Member stated CR#1 had complained of pain and the facility did not address the issue, and told her CR #1 had dementia and was confused. Family Member said CR #1 had her toes amputated in the middle of (MONTH) this year. In an interview on 08/24/19 at 11:56 AM the ADON stated LVN A was completing a weekly skin assessment and noticed four of her toes were darkened on 07/26/19. The physician was notified and an arterial doppler was ordered on [DATE]. She said the NP called on Monday 07/29/19 and asked about the results. She said the results were not available, so the NP ordered CR#1 to be sent to the hospital, and said the NP did not want to wait that long for results. She said the arterial doppler was performed on Monday, 07/29/19. She said on Saturday, 7/27/19, LVN B did call Mobilex regarding arterial doppler to see when they could come to the facility. She said the order was not stat (immediately) and Mobilex said they were backed up and would come as soon as they were able. In an interview on 08/24/19 at 12:11 PM LVN B stated she was expecting a call from Mobilex to confirm CR #1's visit. She called them twice on 07/27/19 to find out when they would come. She said Mobilex told her they had a large volume of work and would make it to the facility on Monday. She said because CR #1's pain did not increase, and the color of her toes did not change more than it was, she did not call physician. She said she put in a note that she called Mobilex and got a confirmation number for doppler. She said she gave the oncoming nurse the information. She said the order was not a 'stat order' and said maybe if it was she would have pushed harder. She said she did not call physician because it was not a STAT order and CR#1's condition did not get worse. In an interview on 08/24/19 at 12:42 PM CNA C stated CR#1 reported pain in her feet, so she notified the nurse. She said CR#1 complained of pain a couple of weeks before she went to the hospital. She said CR #1 would always say her foot hurts, so CNA C would let the nurse know. She said the aides gave CR#1 showers and her toe nails would be long but that was about it. She said if the aides saw any discoloration the aides would notify the nurse. In an interview on 08/24/19 at 12:52 PM CNA D stated she was not aware that CR#1 had to be sent to hospital due to issues with foot. She said CR#1 would complain about pain in her feet, so she notified the nurse. She said CR#1 had pain for two days and the nurse contacted the physician. She said CR#1 went to the hospital on her day off. Observation and interview on 08/24/19 at 1:25 PM in the hospital revealed CR#1 was lying in bed, dressed in a gown, on contact isolation, receiving IV antibiotics and O2 therapy. Resident was confused and could not remember how long she had been at the hospital. She stated her foot had been hurting for months, the facility gave her Tylenol for the pain. CR#1 could not explain exactly when the pain began. Record review of in-service documentation dated 08/27/19 revealed a facility in-service was completed on 08/27/19 regarding change of condition; SBAR documentation for change of condition, documentation of problem and timely solution, notification of Physician/NP/Responsible Party with any change of condition, documentation in 24 hour report book with interventions plus notifications, and notification of ADON for station. In-service had 20 nurse signatures. In an interview on 09/05/19 at 3:29 PM the NP stated she saw CR#1 a few days before she received the call regarding the resident's toes. She said she was receiving Tylenol PRN which was working. She said the resident complained of pain and she wanted it more often to help with pain so she had the order changed to scheduled. She received a call on Friday (07/26/19) regarding the resident's discolored toes, and the toes were cool to touch. She said she ordered the arterial doppler to be done. She said she did not receive a call from the facility regarding the arterial doppler not being able to be performed until Monday. She said the order was not 'stat' so she did not follow up within a few hours or monitor like she would have for a stat order. She said she called the facility on Monday to get the results from the doppler and it had just been completed. She said she did not want to wait for Mobilex to read the results, so she spoke with the physician and had them send the resident out to hospital. In an interview on 09/06/19 at 10:29 AM RN [NAME] stated if a laboratory/diagnostic order was 'stat' Mobilex would come that day. She said if the order was routine, Mobilex would come the same day or the following day. She said if Mobilex could not come the following day she would call the physician to let them know what is going on and get further instructions. She said the nurse would assess the resident and give the physician the findings of the assessment. She said the physician will make the decision to send the resident out or to continue to monitor the resident. In an interview on 09/06/19 at 11:10 AM MA F stated CR#1 had been in pain for a few weeks, and sometimes she could not get up. She said she reported the pain to the nurse. Sometimes CR#1 would not walk due to foot pain. She said one day, CR#1's foot was hurting and she sat down in middle of the hallway. She reported the pain to the nurse, so they would give PRN pain medications. In an interview on 09/06/19 at 11:21 AM LVN G stated sometimes CR#1 would not want to get up from her bed, and she would complain of leg, hand, and foot, pain. In an interview on 09/06/19 at 11:34 AM the DON stated depending on the acuity of the resident, if a resident was stable, and there was no change of condition, the facility would not call the physician to follow up on lab work. She said if the lab work was not scheduled 'stat' then they did not do them right away. She said the arterial doppler was usually a scheduled routine exam. She said Mobilex will let them know when they can make it to the facility. In an interview on 09/06/19 at 12:04 PM the LVN H stated Mobilex usually comes the same day for a stat order and the next day for a routine order. If they do not come within that time frame they will call the physician to get further instructions what to do because the resident may need to be sent out. She said she had not had any problems with them taking more than a day to get labs or diagnostics. In an interview on 09/06/19 at 1:23 PM MA J stated CR#1's her pain level was 5 and 6 on the weekend of 7/27/19, she gave CR#1 scheduled pain medications. She was not sure about PRN pain medications. When she gave the resident medications CR#1 stated she had a pain level of 5 and a pain level of 6. She reported this to the nurse about pain level, she was not sure what nurse did about the pain. In an interview on 09/06/19 at 1:50 PM the DON stated in her opinion CR#1 was given adequate care and there was no need to call the physician. The process of the toes having to be amputated was not an immediate issue and took time to happen. In an interview on 09/20/19 at 1:41 PM, LVN A stated she went to do skin assessment on CR#1 and noticed her toes were discolored. She notified the NP who ordered an Arterial Doppler sometime after 1:00 PM. She notified the family of the situation and contacted Mobilex. She received a confirmation number and advised the oncoming about the resident's status. In an interview on 09/20/19 at 2:15 PM the DON stated the facility completed an in-service on 08/27/19 regarding change of condition, SBAR, proper documentation, and notifications. The facility completed monthly in-services also on change of condition to continually educate the staff. The facility reviewed orders and they don't have any outstanding lab work that needed to be completed. In an interview on 09/20/19 at 2:49 PM the DON stated CR#1 did not have a STAT order. The arterial doppler test was not expected to be completed on Friday 07/26/19. She said if there would have been a change in condition for CR#1 the expectation would have been for the nurse to contact the physician. She said CR#1's condition did not change. She said if the order would have been lab work or chest x-ray the order would have been STAT. She said when CR #1 left the facility, it took 2-3 weeks before her toes were amputated. She said sometimes after residents leave the facility their condition worsens.

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatments and services consistant with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers for 1 of 9 residents ( CR #1) reviewed for pressure ulcers in that: CR#1 was not provided a weekly skin assessment. His last documented skin assessment was dated 6/20/18. There were no additional skin assessments through 7/29/18. CR #1 had no treatment orders for excoriation to the buttocks identified by staff. His skin assessment dated [DATE] identified his skin as not intact-existing. There was no further documentation of skin assessments or orders for treatment. The facility failed to assess and treat a Stage III pressure ulcer for CR #1. CR #1 was assessed as having a Stage III pressure ulcer to the sacrum at the emergency room when transferred to the hospital for a hypoglycemic (low blood sugar) episode on 7/29/18. These failures affected 1 hospitalized resident and placed 15 current residents with pressure ulcers at risk of pain, infection, delayed medical treatment, delayed healing, skin breakdown, and hospitalization . Findings include: Record review of CR#1's admission sheet revealed he was a [AGE] year-old who was initially admitted to the facility on [DATE] and readmitted on [DATE]. His [DIAGNOSES REDACTED]. [DIAGNOSES REDACTED]. He was discharged to the hospital on [DATE]. Record review of CR #1's Quarterly MDS assessment dated [DATE] revealed he was assessed as having a BIMS score of 12 indicating he was moderately cognitively impaired. He had no behaviors or depression noted. He required the extensive, one person assistance of staff with bed mobility, transfers, dressing, and toileting. He required the total assistance of one person for bathing. He was independent with supervision for eating. He was assessed as having range of motion impairment of both upper and lower extremities. CR #1 was always incontinent of bowel and bladder. He was identified as at risk for developing pressure ulcers and was coded as not having a current or healed pressure ulcer. The MDS documented, under skin and ulcer treatments, as being provided a pressure reducing device for his bed. Record review of CR #1's Physician Orders (per DON these were the only orders that would print, because CR #1 was hospitalized and discharged from the electronic medical records system), revealed an order start date of 3/06/18 that stated, Monitor for any signs of infection/discoloration and if any noted, call PCP/Podiatrist. It also revealed that CR #1 had a PRN (as needed) order dated 12/20/17, for [MEDICATION NAME] ([MEDICATION NAME], anti-diarrheal) 2 MG tablet, give 1 tablet by mouth every 8 hours as needed daily. There were no physician orders for skin assessments, medications for skin care, or wound care orders to adress pressure ulcers or excoriation. Record review of CR #1's electronic MAR (eMAR) dated (MONTH) (YEAR) revealed he was given 1 dose of [MEDICATION NAME] 2 MG as ordered on [DATE] at 4:56 pm, 7/23/18 at 8:30 pm and 7/25/18 at 8:21 am. The surveyor requested all the nursing records for CR #1 from 7/23/18 through discharge date of [DATE] from the DON. The DON returned at 5:12 pm on 8/2/18 with nursing documentation dated 7/24/18. The DON then returned on 8/2/2018 at 5:49 pm with more nursing documentation dated 7/26/2018, 7/27/2018 and 7/29/2018. There was no nursing documentation of CR #1's requests for his prn anti-diarrheal or the effectiveness of the medication on his symptoms, in the clinical documents directly viewed by Surveyor in electronic medical record (AHT), or any documents received from the DON on 8/2/18 at 4:47 pm. Record review of CR #1's nurses note dated, 7/27/2018 at 2:24 pm revealed in part .skin w/d (warm and dry) to touch .Dr. A in facility to see resident after assessment and reported about to check stool for [MEDICAL CONDITIONS] d/t (due to) loose stool but no more loose stools present, a new order to d/c (discontinue) that order received. Record review of CR #1's clinical record revealed no documentation of weekly skin assessment sheets for (MONTH) (YEAR). Record review of CR #1's care plans revealed: -- Problem Onset: 3/29/16 I am At Risk for Pain and Skin Breakdown r/t contractures. CR #1's goals included his risk for pain and skin breakdown will be minimized. --Problem Onset: 5/16/15 Potential for skin breakdown related to decreased mobility, incontinence, fragile skin, r/t diabetes; I have dx of Tinea Unguium and Oncholysis(separation of the nail from the nail bed). Goal and Target Date, dated for 10/30/18 read: Will have no new areas of skin breakdown this quarter, and under Approaches, read: Monitor and address contributing factor(s) of (hydration, nutrition, weight, blood glucose, circulation, incontinence, diarrhea). Observe for indications of impaired circulation, of (redness, [MEDICAL CONDITION], etc.) during all personal care. Ensure support and correct alignment of feet, promote circulation and decrease pressure on buttocks and legs. --Problem Onset: 05/16/2015 I am incontinent of bowel/bladder. I'm at risk for constipation, with approaches that included: Observe my skin daily for irritation and redness and Evaluate my bowel pattern. Record review of CR #1's Departmental Notes signed by LVN B, revealed CR #1 was discharged to hospital via 911 on 7/29/2018 for a low blood sugar. Facility documentation also had CR #1's note, time dated and stamped for, 7/29/2018 5:46 PM. Observation and interview with CR #1 on 8/3/18 at 9:13 a.m. at the local hospital revealed he was semi-reclined in a specialized hospital bed. He was initially asleep, but once awake he was alert and oriented to person, place, and time. CR #1 said he was feeling better. He said his sugar (blood sugar) got really low. He said, low, low, low, and that he had been feeling bad for a few days. When asked what he meant by feeling bad, he said that he had been having diarrhea. He became tearful and said, I told them I wasn't feeling well. I told them my butt hurt. But they didn't do nothing. When asked who he told, CR #1 said he told LVN C. Surveyors clarified that he was not speaking of the ADON but of LVN C, and CR # 1 said LVN C. He said that he told LVN C and the doctor about his diarrhea and his butt hurting and they did nothing about it. He said neither one looked at his bottom. He said when he got to the hospital they (hospital staff) told him he had an infection and that he had a wound on his butt. He repeated he kept telling them his butt was sore. During an interview on 8/3/18 with the hospital nurse at that time he confirmed CR #1's statement that he had a wound on his sacrum. The Hospital Nurse said CR #1 was being treated for [REDACTED]. He said that CR #1 admitted to the hospital with [REDACTED].#1 received any specific treatment for [REDACTED]. He gets [MEDICATION NAME] (A type of dressing for wounds). Record review of CR #1's hospital history and physical Final Report dated 07/29/2018 revealed CR #1 reported to hospital physician his symptoms which included, diarrhea, nausea, fatigue, feeling achy and decreased appetite. The hospital plan to treat CR #1 included, initiating antibiotics for a significant urinary tract infection. .We will send the stool for[DIAGNOSES REDACTED]icile testing as well as checking for ova and parasites. Further record review of CR #1's hospital record revealed CR #1 had a consultation on 7/30/18 that read, Final Report, Reason for Consultation: Sacrum stage III pressure ulcer. Patient had this pressure ulcer before hospitalization . Patient is incontinent with [MEDICAL CONDITION] both, gluteal, perineum and scrotum. The document also read History of Present Illness: Patient admitted with malnutrition and wound worsening. Under the heading, Physical Examination: Sacrum wound size about 1.5cm x 1 cm x 0.2 cm Stage III pressure ulcer of both gluteal, perineum, scrotum scattered excoriation very suggestive of incontinence [MEDICAL CONDITION]. The consultation had a recommendation that read as follows: Dolphin bed. Use [MEDICATION NAME] and foam dressing. Use zinc oxide both gluteal, scrotum, and perineum. Will monitor wound. During an interview on 8/3/18 at 12:50 pm the facility's DON said skin assessments were done on all residents upon admission, discharge and weekly. She said the charge nurses completed the weekly skin assessments. She said that the CNA's completed the shower sheets and documented skin concerns on them. She said , Usually the CNA will let us know if there's any problems. The DON was asked for CR #1's Certified Nurse aides shower sheets and nurse's skin assessments for (MONTH) and July. The DON was asked also for CR #1's discharge assessment. Record review and interview with the DON on 8/3/18 at approximately 2:40 pm the DON provided copies of shower sheets, skin assessment sheets and shower schedules. The DON was asked if CR #1 had any other skin assessments, as the only ones received for CR #1, were dated 6/07/18 and 6/20/18. The DON said, This is all he has. The facility also did not provide a discharge assessment for CR #1 prior to exit on 8/8/18. Record review of CR #1's shower sheets, provided by the DON revealed: -6/26/18 (Tuesday), skin marked as intact and bed bath indicated. -6/30/18 (Saturday), Skin not marked as intact or not intact. Blank and no staff signature noted. No bath or shower indicated. -7/10/18 or 7/16/18 date appeared written over and it was unclear whether it was dated the 10th or the 16th. Shower indicated. Skin not marked as intact or not intact, it was left blank. -07/14/18 (Saturday) Shower and shave given. Skin turgor Ok. Skin not marked as intact or not intact. It was left blank. -07/17/18 (Tuesday) Shower and shave given. Skin turgor Ok. Skin not marked as intact or not intact. It was left blank. -7/19/18 (Thursday) Skin marked yes as intact and shower indicated. -07/26/18 (Thursday) Skin turgor marked as Ok. B/B (Bed Bath) given. Skin not marked as intact or not intact. It was left blank. Record review of 11 random residents' shower sheets/Body Audits revealed similar inconsistencies of either not receiving showers or baths or their skin not marked as intact or not intact and left blank, or a combination of both as in the case of CR #1. During an interview on 8/3/18 at 1:00 pm RN A said she had provided care for CR #1 during the week of (MONTH) 23, (YEAR) through (MONTH) 29, (YEAR). She said both the CNA (unidentified) and CR #1 reported to her, that he was experiencing diarrhea. She said she, .checked the order and since he had a prn order for [MEDICATION NAME], I gave it to him and the next day he complained again, so I called the Nurse Practitioner and she ordered a stool sample. RN A said she attempted to collect a stool sample but never obtained it because CR #1 had no more diarrhea. She then said she went and tried to collect a sample, but it was not enough of a sample, It was too small, like nothing. She said she told the doctor this and he discontinued the stool sample order. She said the nurses were to complete a weekly skin assessment. She did not recall doing a skin assessment for CR #1 during the week of 7/23/18 through 7/29/18. She said that CR #1 never reported any pain to her. She denied any knowledge of any skin breakdown or wounds on CR #1. During an interview and record review with LVN C on 8/3/18 at approximately 3:35 pm she said she remembered caring for CR #1 during the week of 7/23/18 through 7/29/18. She said CR #1 had no open areas or wounds. She said she last completed a skin assessment on Wednesday (7/25/18) and demonstrated to surveyor where she would go in the Electronic medical record (EMR) to document skin assessments. No skin assessment for 7/25/18 noted. LVN C said she was not sure why she did not document the skin assessment on CR #1. LVN C was shown the facility skin inspection report the DON provided with her name documented as being the nurse to complete CR #1's skin assessment on 6/20/18. The 6/20/18 entry read, under the heading, Skin status skin not intact-existing. LVN C said she was unsure why she documented that and said, I must have put that by mistake. When asked if she looked at CR #1's skin in the month of (MONTH) excluding Wednesday (7/25/18), she said she could not remember. She confirmed giving the CNAs cream in a medicine cup to put on CR #1's bottom, but she said, I usually didn't have to because he (CR #1) always kept his cream by his bed. She could not really say why but said she thought CR #1 had some skin problems before. During a telephone interview with LVN B on 8/7/18 at 11:35 am she said she provided care for CR #1 on 7/29/18 during the 6-2 shift, the day CR #1 was sent to the hospital. She said in between CR #1's first and second hypoglycemic episodes, she was feeding him some cinnamon roll and then he said he was wet and needed to be changed so I called the certified nurse aides to change him. When asked if it was normal for CR # 1 to be fed she said, No. But he wasn't feeling well. When asked what she meant she said, the resident said he was wet, she said, No and denied any knowledge of diarrhea or loose stools. When asked if she helped the CNA(s) change him, she said, No. She said that no one reported CR #1 had any diarrhea symptoms or loose stools to her. She said CR #1 never reported any diarrhea or butt pain to her on Saturday (7/28/18) or Sunday (7/29/18). She said she did not look at CR #1's skin on 7/29/18 before he went out to the hospital. She said he went out 911. She said that she was aware that the certified nurse aides were changing CR #1 just before transport. She said she was aware they regularly used [MEDICATION NAME] cream on CR #1's bottom and perineum in the past, but she was not sure for how long. She said she did not give the aides any cream from the nurse's cart for CR #1 before he left for the hospital. She said she did not remember the last time she completed a skin assessment on CR #1. Records were requested for CR #1's Electronic medication administration records, and treatment administration records for (MONTH) and (MONTH) of (YEAR) from the DON on 8/3/18 at approximately 1:45 pm and received were the EMAR and ACC Monitoring (Insulin and blood glucose monitoring) records dated for (MONTH) (YEAR) only. Record review of CR #1's (MONTH) (YEAR) eMAR and ACC monitoring records revealed that there was no documentation of weekly skin assessments for the month of (MONTH) (YEAR). The facility did not provide any TAR (treatment administration record) for CR #1. During an interview with CNA A on 8/4/18 at 11:32 a.m. when asked did she remember CR#1, she said, I remember him, I worked with him the last day, the day he went to the hospital. CNA A said she was CR #1's CNA. She said she was CR #1's CNA the weekend before he went to the hospital. She said she shaved him, washed under his arms, and cleaned his peri-area. She said staff usually used a blue container with cream in it to put on CR #1's peri-area, but that day he was out. She said when CR #1 was out of the blue cream she would usually go get the pink paste, but they were out of that too. She said the day CR #1 went out she used A&D (ointment). She said she changed CR #1 that day because he requested her, she usually had CR#1 but helped CNA B that day with CR# 1. She said there were lots of things going on. She said the ambulance was there, LVN B, CNA B, and the medication aide were all present at that time. She said CR#1 was sick, he would sleep in his chair and he would normally be out participating in activities. She said the week prior to leaving for the hospital, he was normal. She said he started sitting in his chair and he had been having diarrhea real bad. She said CR #1 was always having diarrhea, even when she was turning him, the day he left for the hospital. She said, .it (feces) kept coming out. When asked did anyone come in to get a sample, she said no. She continued saying, I told RN A about the diarrhea and she said she would give him something. When asked was she able to get CR# 1 completely clean, she said, Because it (feces) kept coming out, I'm sure he still had some on him. They (the ambulance) took him. He only ate a little for breakfast, the egg. He didn't eat the oatmeal and he drank a whole Sprite. She said, she never saw anything wrong with him that day or the week prior. She said there were no problems on his bottom, but he always requested cream, all the time. She said CR #1 came back from the hospital before, when they did something with his kidneys and he was, .messed up bad on his bottom, scrotum, and inner thighs. She said they treated it with the cream in the blue container and it healed. She said after it was healed she saw no problems. She also said, He's also a heavy wetter. During an interview with CNA B on 8/4/18 at 11:59 a.m. she said she remembered CR #1. She said that on 7/29/18 she was across the hall and CR#1 was screaming. She said she went in his room. She said she got LVN B and CR #1's blood sugar was checked. She said EMS came and then left. She said CR #1 had a bowel movement and CNA A started to clean him up. She said he had diarrhea and had been having it for a couple of days. She said CR #1's bed got messed up and she went to get sheets and gave CNA A the A&D (ointment). She said the second time she went in to CR #1's room, CNA A went in too. She said CR # 1 was breathing heavy but was unresponsive, drooling, and his eyes were partially open. She said LVN B called EMS again. She said they shaved him that day before he left. She said CR #1 had diarrhea a lot, but she could not remember the last time he had it, maybe the week before last. She said she was his CNA and they had to put a cream in a blue jar on him. She said if they ran out of the blue cream, they (the nurses) gave them a barrier cream or A&D (ointment). She said, I didn't see anything coming out of where he had the previous thing, no bleeding or pus or anything. He had what looked like a previous wound that healed but was scabbed over but there wasn't anything coming off or oozing out. She said it was a scab and it was pink. When asked where this area was located on CR #1's bottom she said, On his bottom right at his butt crack. CNA B said, He wasn't getting his showers because whenever you give a shower you shave him, and he wasn't shaved and most of the time on 2-10 shift they be giving a bed bath instead of a shower. His skin down there was pink, not open, it was pretty wide spread. She said she did not report this, because everyone knew he had it. It was there (the pink area on his bottom) and they were giving us cream to put on it, so the nurses knew. She said there was no blood. She said since she had started working there, CR #1 had that spot on his bottom and in between his legs but it was healing. When asked was the spot healing or healed, she said healed. She said there was no redness. She said CR #1 was not saying it was hurting and he would tell you. She said the medicine in the blue jar was kept in the med-cart, but he also may had some by his bedside. During additional interview 8/4/18 at 1:35 p.m. when asked to give a description of the area in regard to his skin CNA B said the area had scabs and was pink, kind of widespread. She said she did not report it to the nurse because it was already there, the nurses were all aware and the nurses had given them cream for it. Record review of CR #1's nurse's notes revealed notes dated 7/24/18, 7/26/18, 7/27/18, and 7/29/18 with no documentaion of any fragile, broken, irritated, scabbed, bleeding, or sensative skin. References were made to skin being w/d (warm and dry) but there was no documentaion clarification to say what part of the body was being felt for the temperature description of warm or what part of the body they were describing as dry. During an additional interview on 8/4/18 at 1:20 p.m. CNA A said when she saw an open skin wound she would tell the nurse. She said that CR #1 had not had any issues, no dry skin, no redness, none of that, it's been a while since I've seen that. She said, Let me take that back. When he's having diarrhea, when I wiped CR # 1, he had a little blood. She said she did not report this to the nurse because she thought the blood may be hemorrhoids. She said she placed cream on him, but she did not tell the nurse. She said, The last time I can remember the last time I saw the little spots of blood was on Monday, 7/23/18. When asked to describe the area of skin in question, she said she thought it was on his cheek and gestured/pointed to her right gluteal cheek towards the center of her buttock. During an interview on 8/5/18 at 1:10 p.m. with the Treatment Nurse and the DON, the Treatment Nurse said usually the nurse applied those medications/ointments (A&D, [MEDICATION NAME], Barrier creams). The Treatment Nurse said, I tell the ADON what I need and she orders it. She said, [MEDICATION NAME] is an actual medication, a prescription, and needs an actual physician's order. She said, since [MEDICATION NAME] is a prescription item, the nurses order it and apply it. She said that most residents had a house barrier cream that they may use if a resident, .is at risk, like incontinent. When asked if a CNA wiped a resident and the resident had a little blood, would that be something they would report. The Treatment Nurse said, Yes, because that's not normal. The Treatment Nurse said, CR #1 would always ask for me to look at his bottom if he had a problem because he's so particular. She said, That's why I'm surprised he didn't say anything. When asked about whether CR #1 had [MEDICATION NAME] she said, He had that ([MEDICATION NAME]) from previous skin breakdown after hospitalization s and I'll be honest, yes, we treated him with that because the Dermaseptic wasn't healing him. The DON then said, Yes, and we used it for the areas between his toes and it helped heal him. The DON described that CR #1's scrotum and perineum were so excoriated from the last hospital stay that, .it looked like he had that flesh-eating bacteria. The DON and Treatment Nurse were both unaware of CR #1 having any wounds or skin concerns. They both said that CR #1 would have told them if he was having any issues with his bottom. The DON also said she knew he sometimes suffered from diarrhea and CR #1 had been having diarrhea, but she was not sure for how long. She denied that CR #1 had any skin issues. When asked if the Treatment Nurse had completed any skin assessments on CR #1, she said she had not because no one told her that CR #1 had any wound or skin issues. The DON said the nurses completed the weekly skin assessments. During an interview on 8/6/18 at 3:35 pm the DON she said normally staff would do a skin assessment if or when a resident transferred to another facility or to the hospital. She said they could do a skin assessment or just include the skin assessment in their note. She said, It's just best practice. Record review of the facility's undated policy and procedure Clinical Care System Guideline entitled Skin Care Guideline, revealed the purpose was to, .Provide a system for evaluation of skin at risk, identify individual interventions to address risk and process for care of changes/disruption in skin integrity: All those admitted will be observed for baseline skin condition and evaluated for risk of skin breakdown within 24 hours of admission. The findings will be documented in the Wound Module electronic record. Weekly review of the patient's skin will be completed by the nurse and documented in the electronic medical record. Resident will be observed by the CNA (Certified Nursing Assistant) for reddened/open areas and [MEDICAL CONDITION] of feet or sacrum, changes will be reported to the licensed nurse and documented when an open area is identified; notify physician and document notification . Record review of the facility's Policy and Procedure entitled Notification of Change in Patient/Resident Health Status, dated (MONTH) (YEAR), revealed, The facility will consult the resident's physician, nurse practitioner or physician assistant, and if known notify the resident's legal representative or an interested family when there is .(C) a need to alter treatment significantly (i.e. a need to discontinue an existing form of treatment due to adverse consequences, or to commence to a new form of treatment). Criteria: A need to alter treatment significantly means a need to stop a form of treatment because of adverse consequences-Notification: Depending on the nursing assessment appropriate notification may be immediate to 48 hours. (D) a decision to transfer or discharge the resident from the facility. (E) Expected or unexpected deaths-Criteria: Appropriate notification time, immediate. This policy further reveals, nursing judgement is an integral part of the skilled care provided in this facility, therefore, such judgement must be applied in a case by case basis in keeping with acceptable nursing practice. Definition: Immediate: As soon as possible or no longer than 24 hours. Non-emergent issues will be addressed by routine communication to the patient representative with a timeframe of no more than 72 hours. Record review of the undated Interact version 4.0 tool, Stop and Watch Early Warning Tool revealed the following: If you have identified a change while caring for or observing a resident, please circle the change and notify a nurse. Either give the nurse a copy of this tool or review it with her/him as soon as you can.C-Change in skin color or condition . The CMS- 672 Resident Census and Conditions of Residents dated 6/21/18 revealed 15 residents in the facility with pressure ulcers.

Based on observation , interview, and record review the facility failed to ensure 2 of 18 residents ( CR #1 and Resident #15) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: --CR#1 was not provided with catheter assessment and care from admission on [DATE] through discharge on [DATE] to prevent and then treat injury to his penis. His penis was split from the meatus down the shaft to the scrotum. --Resident #15 had a significant change in condition on [DATE] that was not treated emergently resutling in delayed transportation, intervention, and treatment. He later died in the hospital on [DATE]. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected 1 hospitalized and 1 current resident and placed 11 additional residents in the facility with an indwelling catheter at risk of injury, harm, delayed medical treatment intervention, and possible hospitalization or death. Intake # 7 and # 2 Findings include: Closed Record #1 Record review of CR #1's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was discharged to the hospital on [DATE]. Record review of CR #1's Admission Nurse's notes by LVN U dated [DATE] revealed CR #1 was incontinent of bowel and bladder and there was no documentation of the presence of an indwelling urinary catheter. No other nurses' notes showed he had an indwelling catheter or that the catheter was changed through the time he was discharged . Record review of CR # 1's Admission Clinical Health Status note dated [DATE] documented his elimination and skin condition as follows: --Bladder: Incontinent. There was no documentation of him having an indwelling urinary catheter. The notes documented he was assessed as, incontinent of bowel and bladder. Record review of CR #1's Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 indicating he had severely impaired cognition. He required extensive assistance for dressing, toilet use, and personal hygiene. He required total care with bathing. CR #1 needed supervision for eating and [DIAGNOSES REDACTED]. The MDS did not note the presence of his indwelling urinary catheter. His skin assessment revealed no pressure ulcer but that the resident was at risk of developing pressure ulcers. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed no BIMS score documented. He required extensive assistance for dressing, toilet use, personal hygiene, and total care with bathing. CR #1 needed limited assistance for eating. Assessment of bowel and bladder revealed he was always incontinent of bowel and frequently incontinent of bladder. No skin assessment documented. Record review of Resident # 1's Care Plan for Activities of daily living (ADL) , not dated and not signed, had conflicting interventions. The intervention for bladder function revealed staff to assist resident as needed and record each shift whether he had voided. The same care plan had another intervention that stated resident had urinary catheter and directed staff to provide catheter care and record output. Record review of CR #1's unsigned physician's orders [REDACTED]. There were no admission orders [REDACTED] Record review of CR #1's Medication Admission Record dated July and [DATE] revealed no documented schedule or care for his indwelling urinary catheter. Record review of CR #1's Progress Notes for the month of [DATE] documented by the Nurse Practitioner (NP) for the Therapy department revealed as follows: --[DATE]: He was also complaining about pain in his 'privates.' --[DATE]: He wanted to know who was taking care of his privates now and he was told that the PCP (Primary Care Physician) at Afton was in charge. I discussed his problem with the ADON and she will talk to the patient about his concerns. He stated that other than his pain in his privates he felt ok. --[DATE]: The patient was still complaining about not understanding why he has a problem with his 'privates'. Per nursing, he only seems to complain about the catheter when I am present. Record review of CR#1's clinical record revealed no documentation of follow up care or physician notification. During an interview on [DATE] at 3:23 p.m. with the House Supervisor at the local hospital, she said her concern was that upon admission, CR #1's Foley catheter was dirty, his penis was filleted, it was open and he (Resident # 1) was septic. Record review of CR #1's medical records from the the local hospital obtained on [DATE] revealed he was admitted to the emergency room of the hospital on [DATE] at 13:22 p.m. and upon nursing assessment, it was noted, .Foley in place extremely dirty with sediments all along tube walls, patient's penis is split open from the bottom along the shaft. Urine dark brown It was also documented that CR #1 had [MEDICAL CONDITION] +2 to Right upper arm, right elbow, right forearm, left midcalf, left ankle, left upper arm, left elbow, left forearm, right midcalf and right ankle. Record review of the Physician's Progress Notes from the local hospital dated [DATE] at 9:55 p.m. revealed assessment and plan as follows: --Sepsis secondary to healthcare-associated pneumonia and urinary tract infection secondary to [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) and [MEDICATION NAME]. Urologist consult report from the local hospital dated [DATE] revealed as follows: --the patient noted on a thorough exam by ICU to have an indwelling Foley catheter for unknown reasons and found to have significant traumatic [DIAGNOSES REDACTED] from the Foley catheter. --the patient was previously admitted in the hospital in July and was discharged after a two-week stay to nursing home with a Foley catheter --Foley catheter presumed to be in place for likely [MEDICAL CONDITION] and there was no records found to document whether Foley catheter has been changed or not at the nursing home. The Urologist assessment revealed that the indwelling catheter was in place with approximately 5 cm of traumatic [DIAGNOSES REDACTED] and ventral erosion likely from Foley catheter and stated that the patient needs the Foley catheter to be exchanged and that he could benefit from a suprapubic tube in the future if he desires. Additionally, Nurses Shift Goals- Integumentary from the local hospital documented on [DATE] at 7:00 a.m. noted penile shaft open wound approx. ,[DATE] inch long, monitor s/sx (signs/symptoms) of infection. Observation and interview of CR #1 in his room at the local hospital on [DATE] at 10:59 a.m. with the hospital nurse and social worker present revealed he was alert and oriented to person and place. His right hand was swollen. He answered questions appropriately and coherently. CR #1 said, I will be [AGE] years old and never had something like this happen like this, someone cut it-someone cut it completely open down the shaft . He added the service he received at Afton Oaks was not good. He said, It looks like someone didn't like me, for some reason but I hadn't did anything to anyone, I don't want to go back there, my family member will take me home to (name of home State). CR #1 was in Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his hospital nurse, she said it did not look like his catheter had been taken care of. She said there were old wounds to the front and lateral shaft. She said there was a large laceration on his penis draining pus and the meatus was sliced open, not healed, and with a pink bed to it. Observation of CR #1 in his room at the Medical Center on [DATE] at 8:15 a.m. revealed he was alert and oriented to person and place. His skin was dry with mild swelling to his extremities. He answered questions appropriately and coherently. CR #1 said he was butchered and sore. CR #1 remained on isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his nurse, it was noted that he had a severe cut from the tip of the penis along the shaft and down to the bottom of his penis with an open wound around the shaft and about 80% granulation tissue and 20% slough. He had no Pressure ulcer. CR #1 was still being treated with intravenous and oral antibiotics. The hospital nurse said they were treating the wound with wet to dry dressing changes. During an interview on [DATE] at 4:40 p.m., the Director of Nursing said that CR #1 was admitted into the facility with an indwelling catheter on [DATE]. When asked why his admission MDS assessment did not show documentation of the catheter, she said that she did not know. When asked about CR #1's wound assessment, the DON said his pressure ulcer was a stage 2 on his sacrum. She said that she did the resident's admission skin assessment in the presence of two other staff and that the wound was a stage 2 and it healed within three days. During an interview on [DATE] at 5:24 p.m. with CNA 57 in regards to CR #1 she was asked did she ever provide care for him and she answered, I don't remember, never took care of him. During an interview on [DATE] at 5:45 p.m., the DON said CR #1 was admitted from hospital with the catheter and that it was placed on [DATE] at the hospital. She also said the resident had the catheter placed due to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder. During an interview on [DATE] at 10:13 a.m. with LVN CE, she said in regards to CR #1 he used to sing and everything while doing his care. His right arm was swollen when he came. She said she would help the Treatment Nurse turn him. She said he had a Foley catheter. She said she knew she had taken care of him through the week but could not remember the day. She said his hand was hurting and she gave him a [MEDICATION NAME] and breathing treatment. She said he was sitting up in a chair. She said she could remember that when you got him out of bed, all he wanted to do was go back to bed and he liked to talk. During an interview on [DATE] at 11:00 a.m., the Treatment Nurse (RN AB) said CR #1 had intermittent confusion, his bottom and scrotum were intact. He had a Foley catheter. During an interview on [DATE] at 11:43 a.m. with CNA 31, she said she remembered CR #1. She said she was out for about 6 weeks and returned on the 7th of August. She said CR #1 was a real nice gentleman. She said he started going to the dining room, was taking therapy, and she would give him his showers on Monday, Wednesday and Friday. She said there were no concerns for him. She said he had a little red area on his buttocks and she documented it on the shower sheet and in a couple of days the red area was gone. She said he was incontinent of both bowel and bladder, no Foley or ostomy, but could not really remember. During an interview on [DATE] at 11:51 a.m. with CNA 44, she said that CR #1 was nice, sweet, and that she helped him with everything, he asked, showers, and assist to chair. She said he was incontinent of bowel and bladder and had a urinary catheter. She said there were no problems or skin issues. During an interview on [DATE] at 12:00 p.m., the ADON when asked what she knew about CR #1, she said he was admitted during the middle of July, had an indwelling catheter, and [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. She said the resident was cognitively confused intermittently and complained of pain to the Right shoulder. When asked whether she had any discussion with CR #1's Physician or NP's recently she said not that she could .remember or think of. When asked whether she had discussed with the Nurse Practitioner (NP) with the therapy department she said that Nurse Practitioner (NP) on one occasion said to her in a joking manner something about the resident's catheter and that he, CR #1, said he was going to call an Attorney. She said she did not know what the complaint was about and that it took place about 3 weeks prior. She also said she asked the nurses if CR #1 had complained to them about his catheter and they said no. When asked whether he was being given showers she said she had seen staff take him for showers. A request was made to review the resident's shower sheets from admission to his discharge. When asked if the NP discussed with her the Resident's complaint of pain of his privates she said she never discussed anything about that with her. She also said the resident had never complained to her or the staff about pain to his private area or with the catheter. When asked if she assessed the resident's catheter when the NP notified her of resident's complaints about his catheter, she said that she looked at the drainage bag and tubing and it was clean and she did not check the catheter or his penis because he was sitting in his chair. She said if the NP had told her about pain in the resident's private area she would have assessed the area and would have notified the DON and resident's Physician. During a telephone interview on [DATE] at 12:06 p.m., CNA 16 said that she worked at the facility PRN (as needed) and that she had taken care of CR #1. She said that he had a Foley catheter and sores in his private area, looks like he has a cut down there. When asked if she notified her nurse, she said she did not notify the nurse because the sores and cut looked like they had been there for a long time. She said she would have thought the nurses should have known and that as a PRN staff she had not worked since the last few weeks. She said that while cleaning him she had to be careful because it hurt him. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 16 took care of him on [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. Additionally, record review of the Catheter Output Roster revealed that from [DATE] (admitted ) to [DATE] (discharge date ) staff were documenting that Catheter care was provided each day as follows: [DATE] - 1 time [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 4 times [DATE] - 2 times [DATE] - 1 time [DATE] - 5 times [DATE] - 2 times [DATE] - 3 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 1 time [DATE] - 5 times [DATE] - 3 times [DATE] - 2 times No documentation from any staff reporting of CR #1 having wound to his penis and sediments in his urine. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 57 signed indicating she provided care for CR #1 on the following days: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 2:47 p.m. with CNA 57, she was asked about caring for CR #1 again and was shown his picture from his medical record and where she had documented care, including Foley catheter care. She said she recalled care provided saying she never took care of his catheter but could remember feeding him. When asked why did she sign that all care was provided on her on behalf, she replied, that she went around asking other CNA's about their residents things like output and care and entered the information in the kiosk for them in order to keep it from going into red. She said she would go ask the CNA's how much a resident ate and would go report to the nurse if there was a change in condition. She said no one ever told her about a problem with CR #1's catheter or penis but if they did, they were supposed to report it to the nurse. During an interview on [DATE] at 12:50 p.m., the DON she said CR #1 was admitted to the facility with an indwelling catheter but could not remember whether it was changed or not and that best practice should be to document date /time when catheter/bag/ tubing was changed. She also said she did not receive any report and did not hear that he was complaining of pain in his private area. The DON said the implications of not assessing a resident's catheter could be possible retention of urine, and swelling in his pubic area and penis. When asked if staff doing catheter or incontinent care would have seen it if the resident had swelling, sores, and cuts, she said yes, they should have noticed that but if they did not report it nobody would know. Record review of CR #1's shower sheet for [DATE] and [DATE] revealed no documentation of any abnormal finding or wound to the resident's penis. There were no shower sheets for the other days from [DATE] to [DATE]. During a telephone interview on [DATE] at 3:50 p.m. with Physician A, he said he did not receive any calls from the facility regarding sores/cuts or wound on CR #1's penis and he was not notified about his having sediment in his urine. During an interview on [DATE] at 11:55 a.m., the NP for the therapy department said CR #1 had complained to her a couple of times that he was having pain in his privates anytime he saw her and he explained to her that the pain could be from his catheter. The NP said she checked with the nurses and they said he did not complain to them about pain in his catheter or his private area. She also said she had a discussion with the ADON regarding the resident's complaint of pain to his privates and asked for her to look into it and follow up with his Physician. When asked what she would usually do if she had any issues or complaints from any resident, she said she would notify nursing and if the resident's Physician was available, she would mention it to them. She said it was not in her role to assess resident's privates/penis but to notify nursing and she was not sure if he had any problem with his privates or that it was emergent and did not convey it to the ADON as if it was emergent. When asked when she started seeing CR #1, she said from [DATE] to [DATE]. During an interview on [DATE] at 11:25 a.m., the DON when asked whether a staff should document care another person performed, she said that catheter care was done by CNA's and nurses performed care of Suprapubic catheters. She said that whoever did the care should document it and that a CNA should not document care performed by another CNA. Resident #15 Record review of Resident #15's Admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #15's Admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS score of 11 indicating moderately impaired cognition. He was totally dependent on staff for transfers, dressing, eating, toilet use, personal hygiene, and bathing. He needed the extensive assistance of staff with bed mobility. Record review of Resident #15's plan of care dated [DATE] revealed a plan of care for being at risk for complications related to Cardiac Pace Maker in place, at risk for impaired cardiovascular functions, staff assistance for all ADL's, full code, difficulty recalling recent events and use of indwelling suprapubic catheter due to [MEDICAL CONDITION] bladder and at risk for developing Urinary Tract Infections. Record review of Resident #15's Nurses notes for [DATE] revealed documentation of vital signs/status of resident ( per nursing - time reflected was when nurses documented the vitals and not necessarily when the vitals were taken) as follows: --[DATE] at 6:25 a.m. - RN AA documented Resident #15's Temperature 100.5 degrees Fahrenheit, axillary. MD notified, STAT labs and Chest X-ray ordered. --[DATE] at 11:03 a.m. - LVN/Unit Manager (UM) documented that Chest X-ray result revealed left lower lobe increased opacity with consideration for pneumonia, atelectasis and pleural effusion. Notified attending Physician and awaiting response. --[DATE] at 11:21 a.m. - RN AD documented for vital signs taken at 9:00 a:m (per interview with RN AD on [DATE] at 12:20 p.m.): O2 Saturation (SAT) 82% on Room Air (RA), Respiration (Resp) 20, Pulse(P) 123 bpm; resident was put on Oxygen (O2) at 2 liters and Blood Pressure (BP) ,[DATE] mmHg; Physician/Responsible Party (RP) notified. --[DATE] at 11:30 a.m. - RN AD documented she noted the Suprapubic catheter was draining scant urine, MD notified with order to replace catheter, consent obtained from responsible party. --[DATE] at 1:17 p.m. - LVN M documented Resident was difficult to arouse upon verbal and tactile stimuli upon arrival of a visitor. Resp. (respirations) 14 bpm (breathes per minute) , BP (blood pressure) ,[DATE], P (pulse) 62 and no temp. (temperature) and no 02 SAT (oxygen saturation). --[DATE] at 1:32 p.m. - LVN M documented temp. 99 temporal, MD notified and ordered to send Resident #1 out to VA hospital. Contracted Ambulance Response notified at 1:00 p.m. --[DATE] at 2:15 p.m. - LVN M documented - Non rebreather mask applied to resident with O2 (Oxygen) at 15 liters, resident remains stable at this time, 911 arrived at 2:10 p.m., report given, resident still breathing. --[DATE] at 3:00 p.m. - LVN M documented - Addendum: Contracted transport ambulance refused to transport resident due to their assessment of resident which resulted in 911 being called. --[DATE] at 3:31 p.m. - LVN/UM documented a late entry for 2:20 p.m. - 911 in room performing Cardiopulmonary Resuscitation (CPR) on resident starting approximately 2:15 p.m. and [MEDICATION NAME] 15 minutes. Resident left via stretcher escorted by 911 staff. Family members at bedside, attending physician updated. During an interview with Physician #2 on [DATE] at 3:15 p.m. he said that initially he was called about Resident #15 and was told that the resident was not doing well and he ordered some blood work, urine test and chest x-ray. He said he received another call notifying him of the chest x-ray results and that they had not received the results of other blood work. The Physician initially said he believed the staff did what they were supposed to do. He said he talked to the staff at the hospital and they said the resident basically coded. He also said when he spoke with the Medical Examiner he told him he did not need an autopsy and that the body had been released to the funeral home. When asked to explain further, he said that Medical examiners look for wrong doing for an autopsy to be done. When asked if he left any parameters or guidelines as to when to be called he said no and that it was easier to just call him when they have any issues. When asked of the Physician if the facility notified him when Resident #15's O2 SAT dropped to 82% in the morning; when they could not get O2 SAT on him later that morning; when his BP dropped to ,[DATE] and when he became difficult to arouse upon verbal and tactile stimuli, he said he was not notified of those findings and did not know about the situation. When asked what he would have expected the facility to do in those situations, he said he would expect staff to call him immediately. During a confidential interview the person said that they were concerned about the amount of time it took for Resident #15 to receive medical attention including transporting the resident to the hospital. This person raised concerns about the facility in that they failed to call 911 earlier and felt that Resident #15 would still be alive if medical attention needed and transport by 911 were contacted. They said there was confusion during his time of need. He stayed at the facility for two hours instead of being transferred properly. During an interview on [DATE] at 1:45 p.m., LVN M said she was the desk nurse on the date of the incident, [DATE] and that as the desk nurse she was responsible for charting skin assessments, weekly notes, antibiotic charting, and getting paper work ready for resident appointments amongst other tasks. She said she knew what was happening when a visitor came to the desk and said she was Resident #15's visitor and his condition was not good and wanted to know what was happening. She also said RN AD was the floor nurse that had the resident. She further said she went to the room with RN AD to assess the resident and did vital signs on him as follows: BP ,[DATE], P 62, and Resp. ,[DATE] and could not get O2 reading. She said the resident did not respond to his name. She said RN AD left the room and came back and told her the resident was going to be sent out. At about 1:30 p.m. LVN M wrote the transfer order, and prepared transfer papers. She said she did not know what time the transportation was called but noted transport arrived about 1:50 p.m. She said that when transport arrived, they came to the desk and told her they could not transport Resident #15 because they did not have the proper equipment. She called the DON and she said to call 911. When 911 staff came most of the staff went to the room. She said she documented what she was asked to write by LVN/UM. When asked what she should do when a resident had a change in condition, she said assess the resident, obtain vital signs, call the MD, notify DON/RP, and follow MD orders. She said if a resident's condition became worse she would call 911 and notify the MD. LVN M was able to enumerate what to do when she got a new admission including assessment of skin and indwelling catheter - when it was inserted and how urine looks. She said she should get physician's orders [REDACTED]. During an interview on [DATE] at 3:30 p.m., LVN/UM said she was made aware by RN AD that Resident #15 had a temperature of 100.5 degrees Fahrenheit and she gave him Tylenol. She said they document vital signs on their nurse's notes and some on the Medication Administration Record [REDACTED]. She said she was on another hall when she learned about the resident's condition and on getting to the room [ROOM NUMBER] was already there doing CPR. She said the DON with other nurses were in the room. She said she knew the MD was notified of X-ray results but not when his O2 SAT dropped/vital signs. When asked what staff should do when a resident had a change in condition, said they should assess resident including getting vital signs and O2 SAT, call MD and RP and carry out MD orders. She also said others should be documented in the nurse's notes and on their SBAR. She said nurses should not administer medications/treatments without a physician's orders [REDACTED]. During an interview on [DATE] at 5:12 p.m., the DON when asked whether she knew Resident #15 had a change in condition and what happened, she said she knew he had a change in condition and was going to the hospital. She then said she received a call from the nurse that the transport company refused to transport Resident #15 because they could not get an O2 SAT reading on him. She said 911 was already called. She said when she got to the room the resident was still breathing, 911 staff came, checked and obtained his pulse, and then started bagging him and putting in an IV catheter. When the 911 staff came into the room, they intubated him and started CPR. She further said they worked on him for a while before taking him to the ER. When asked whether they should have called 911 instead of the ambulance transport service they use she said the staff had called the ambulance transport service because the resident was clinically stable. She also said when his O2 SAT dropped to 82% Oxygen was applied and he was always having high heart rate even on admission. She said she did not know staff could not get his O2 SAT at 1:17 p.m. as per the nurse's notes and did not know if vital signs were done between the hours of 11:21 a.m. and 1:17 p.m. She said there were many people in the room and thought vital signs were done during that time frame. Requested documentation of the vital signs/monitoring of the resident during the time frame, none was provided provided prior to exit on [DATE]. When the DON was asked if she conducted an investigation regarding the incident, she said yes and she felt anything that needed to be done was done. Surveyor requested for the investigation report. The DON left the room and returned about 10 minutes later and said she did not write the report unless the surveyor wanted her to go and write one then. During an interview on [DATE] at 10:00 a.m., the DON when asked who was responsible for making decisions as to whether to call 911 or call their contracted Ambulance service she said the Charge Nurse was the person to make the decision. If the condition worsened, the nurses could make the decisions and then notify her. She said she could update or change the decision if she was available. When asked if Resident #15's Physician had parameters or guidelines as to when staff should call him, she said no that only Resident #1's Physician had parameters. During an interview with the contracted ambulance transport dispatcher on [DATE] at 11:13 a.m., he said he received the call from Afton Oaks around 1:00 p.m. and when he asked the nurse the resident's status, she said Altered Mental Status and that it took staff about ½ hour to get to the facility. He said the staff that went to the facility said upon arrival, the nurse said the resident just got sick. They said that when they got to the room, the resident was breathing but they could not get his Oxygen Saturation on him with their machine. So, they advised them to call 911 and left. Requested for a copy of their run sheet. He said he would fax it. During a telephone interview on [DATE] at 12:20 p.m., RN AD acknowledged she had Resident #15 on the day shift on [DATE]. She said that when she made rounds that resident was talking and carried on conversation. She said she took the resident's vital signs between 9:00 a.m. and 9:30 a.m. and his O2 SAT was low. She said she notified her supervisor - LVN/UM, put him on O2 at 2 liters and notified Physician #2. She said resident had a temperature and was given Tylenol and Physician #2 was also notified and he ordered Stat laboratory tests, urine

Based on observation, interview and record review, the facility failed to consult with the physician when a significant change in condition occurred for 2 of 18 residents (CR#1 and #15) reviewed for physician consultation in that: --CR#1 complained of pain to his private area on [DATE] and the facility failed to consult with his physician. On [DATE] he was discharged to a local hospital for respiratory issues. He had a severe cut from the top of the penis along the shaft and down to the bottom of his penis with an open wound around the shaft. --Resident #15 had a significant change in condition at approximately 9.00 am - 9:30 am on [DATE] and was not monitored for approximately two hours. His physician was not notified of resident's condition and he received no reassessment. He later died in the hospital. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected 1 hospitalized and 1 current resident and placed 11 additional residents in the facility with an indwelling catheter at risk of injury, harm, delayed medical treatment intervention, and possible hospitalization or death. Intake # 7 and # 2 Findings include: Closed Record #1 Record review of CR #1's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was discharged to the hospital on [DATE]. Record review of CR #1's Admission Nurse's notes by LVN U dated [DATE] revealed CR #1 was incontinent of bowel and bladder and there was no documentation of the presence of an indwelling urinary catheter. No other nurses' notes showed he had an indwelling catheter or that the catheter was changed through the time he was discharged . Record review of CR # 1's Admission Clinical Health Status note dated [DATE] documented his elimination and skin condition as follows: --Bladder: Incontinent. There was no documentation of him having an indwelling urinary catheter. The notes documented he was assessed as, incontinent of bowel and bladder. Record review of CR #1's Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 indicating he had severely impaired cognition. He required extensive assistance for dressing, toilet use, and personal hygiene. He required total care with bathing. CR #1 needed supervision for eating and [DIAGNOSES REDACTED]. The MDS did not note the presence of his indwelling urinary catheter. His skin assessment revealed no pressure ulcer but that the resident was at risk of developing pressure ulcers. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed no BIMS score documented. He required extensive assistance for dressing, toilet use, personal hygiene, and total care with bathing. CR #1 needed limited assistance for eating. Assessment of bowel and bladder revealed he was always incontinent of bowel and frequently incontinent of bladder. No skin assessment documented. Record review of Resident # 1's Care Plan for Activities of daily living (ADL) , not dated and not signed, had conflicting interventions. The intervention for bladder function revealed staff to assist resident as needed and record each shift whether he had voided. The same care plan had another intervention that stated resident had urinary catheter and directed staff to provide catheter care and record output. Record review of CR #1's unsigned physician's orders [REDACTED]. There were no admission orders [REDACTED] Record review of CR #1's Medication Admission Record dated July and [DATE] revealed no documented schedule or care for his indwelling urinary catheter. Record review of CR #1's Progress Notes for the month of [DATE] documented by the Nurse Practitioner (NP) for the Therapy department revealed as follows: --[DATE]: He was also complaining about pain in his 'privates.' --[DATE]: He wanted to know who was taking care of his privates now and he was told that the PCP (Primary Care Physician) at Afton was in charge. I discussed his problem with the ADON and she will talk to the patient about his concerns. He stated that other than his pain in his privates he felt ok. --[DATE]: The patient was still complaining about not understanding why he has a problem with his 'privates'. Per nursing, he only seems to complain about the catheter when I am present. Record review of CR#1's clinical record revealed no documentation of follow up care or physician notification. During an interview on [DATE] at 3:23 p.m. with the House Supervisor at the local hospital, she said her concern was that upon admission, CR #1's Foley catheter was dirty, his penis was filleted, it was open and he (Resident # 1) was septic. Record review of CR #1's medical records from the the local hospital obtained on [DATE] revealed he was admitted to the emergency room of the hospital on [DATE] at 13:22 p.m. and upon nursing assessment, it was noted, .Foley in place extremely dirty with sediments all along tube walls, patient's penis is split open from the bottom along the shaft. Urine dark brown It was also documented that CR #1 had [MEDICAL CONDITION] +2 to Right upper arm, right elbow, right forearm, left midcalf, left ankle, left upper arm, left elbow, left forearm, right midcalf and right ankle. Record review of the Physician's Progress Notes from the local hospital dated [DATE] at 9:55 p.m. revealed assessment and plan as follows: --Sepsis secondary to healthcare-associated pneumonia and urinary tract infection secondary to [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) and [MEDICATION NAME]. Urologist consult report from the local hospital dated [DATE] revealed as follows: --the patient noted on a thorough exam by ICU to have an indwelling Foley catheter for unknown reasons and found to have significant traumatic [DIAGNOSES REDACTED] from the Foley catheter. --the patient was previously admitted in the hospital in July and was discharged after a two-week stay to nursing home with a Foley catheter --Foley catheter presumed to be in place for likely [MEDICAL CONDITION] and there was no records found to document whether Foley catheter has been changed or not at the nursing home. The Urologist assessment revealed that the indwelling catheter was in place with approximately 5 cm of traumatic [DIAGNOSES REDACTED] and ventral erosion likely from Foley catheter and stated that the patient needs the Foley catheter to be exchanged and that he could benefit from a suprapubic tube in the future if he desires. Additionally, Nurses Shift Goals- Integumentary from the local hospital documented on [DATE] at 7:00 a.m. noted penile shaft open wound approx. ,[DATE] inch long, monitor s/sx (signs/symptoms) of infection. Observation and interview of CR #1 in his room at the local hospital on [DATE] at 10:59 a.m. with the hospital nurse and social worker present revealed he was alert and oriented to person and place. His right hand was swollen. He answered questions appropriately and coherently. CR #1 said, I will be [AGE] years old and never had something like this happen like this, someone cut it-someone cut it completely open down the shaft . He added the service he received at Afton Oaks was not good. He said, It looks like someone didn't like me, for some reason but I hadn't did anything to anyone, I don't want to go back there, my family member will take me home to (name of home State). CR #1 was in Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his hospital nurse, she said it did not look like his catheter had been taken care of. She said there were old wounds to the front and lateral shaft. She said there was a large laceration on his penis draining pus and the meatus was sliced open, not healed, and with a pink bed to it. Observation of CR #1 in his room at the Medical Center on [DATE] at 8:15 a.m. revealed he was alert and oriented to person and place. His skin was dry with mild swelling to his extremities. He answered questions appropriately and coherently. CR #1 said he was butchered and sore. CR #1 remained on isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his nurse, it was noted that he had a severe cut from the tip of the penis along the shaft and down to the bottom of his penis with an open wound around the shaft and about 80% granulation tissue and 20% slough. He had no Pressure ulcer. CR #1 was still being treated with intravenous and oral antibiotics. The hospital nurse said they were treating the wound with wet to dry dressing changes. During an interview on [DATE] at 4:40 p.m., the Director of Nursing said that CR #1 was admitted into the facility with an indwelling catheter on [DATE]. When asked why his admission MDS assessment did not show documentation of the catheter, she said that she did not know. When asked about CR #1's wound assessment, the DON said his pressure ulcer was a stage 2 on his sacrum. She said that she did the resident's admission skin assessment in the presence of two other staff and that the wound was a stage 2 and it healed within three days. During an interview on [DATE] at 5:24 p.m. with CNA 57 in regards to CR #1 she was asked did she ever provide care for him and she answered, I don't remember, never took care of him. During an interview on [DATE] at 5:45 p.m., the DON said CR #1 was admitted from hospital with the catheter and that it was placed on [DATE] at the hospital. She also said the resident had the catheter placed due to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder. During an interview on [DATE] at 10:13 a.m. with LVN CE, she said in regards to CR #1 he used to sing and everything while doing his care. His right arm was swollen when he came. She said she would help the Treatment Nurse turn him. She said he had a Foley catheter. She said she knew she had taken care of him through the week but could not remember the day. She said his hand was hurting and she gave him a [MEDICATION NAME] and breathing treatment. She said he was sitting up in a chair. She said she could remember that when you got him out of bed, all he wanted to do was go back to bed and he liked to talk. During an interview on [DATE] at 11:00 a.m., the Treatment Nurse (RN AB) said CR #1 had intermittent confusion, his bottom and scrotum were intact. He had a Foley catheter. During an interview on [DATE] at 11:43 a.m. with CNA 31, she said she remembered CR #1. She said she was out for about 6 weeks and returned on the 7th of August. She said CR #1 was a real nice gentleman. She said he started going to the dining room, was taking therapy, and she would give him his showers on Monday, Wednesday and Friday. She said there were no concerns for him. She said he had a little red area on his buttocks and she documented it on the shower sheet and in a couple of days the red area was gone. She said he was incontinent of both bowel and bladder, no Foley or ostomy, but could not really remember. During an interview on [DATE] at 11:51 a.m. with CNA 44, she said that CR #1 was nice, sweet, and that she helped him with everything, he asked, showers, and assist to chair. She said he was incontinent of bowel and bladder and had a urinary catheter. She said there were no problems or skin issues. During an interview on [DATE] at 12:00 p.m., the ADON when asked what she knew about CR #1, she said he was admitted during the middle of July, had an indwelling catheter, and [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. She said the resident was cognitively confused intermittently and complained of pain to the Right shoulder. When asked whether she had any discussion with CR #1's Physician or NP's recently she said not that she could .remember or think of. When asked whether she had discussed with the Nurse Practitioner (NP) with the therapy department she said that Nurse Practitioner (NP) on one occasion said to her in a joking manner something about the resident's catheter and that he, CR #1, said he was going to call an Attorney. She said she did not know what the complaint was about and that it took place about 3 weeks prior. She also said she asked the nurses if CR #1 had complained to them about his catheter and they said no. When asked whether he was being given showers she said she had seen staff take him for showers. A request was made to review the resident's shower sheets from admission to his discharge. When asked if the NP discussed with her the Resident's complaint of pain of his privates she said she never discussed anything about that with her. She also said the resident had never complained to her or the staff about pain to his private area or with the catheter. When asked if she assessed the resident's catheter when the NP notified her of resident's complaints about his catheter, she said that she looked at the drainage bag and tubing and it was clean and she did not check the catheter or his penis because he was sitting in his chair. She said if the NP had told her about pain in the resident's private area she would have assessed the area and would have notified the DON and resident's Physician. During a telephone interview on [DATE] at 12:06 p.m., CNA 16 said that she worked at the facility PRN (as needed) and that she had taken care of CR #1. She said that he had a Foley catheter and sores in his private area, looks like he has a cut down there. When asked if she notified her nurse, she said she did not notify the nurse because the sores and cut looked like they had been there for a long time. She said she would have thought the nurses should have known and that as a PRN staff she had not worked since the last few weeks. She said that while cleaning him she had to be careful because it hurt him. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 16 took care of him on [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. Additionally, record review of the Catheter Output Roster revealed that from [DATE] (admitted ) to [DATE] (discharge date ) staff were documenting that Catheter care was provided each day as follows: [DATE] - 1 time [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 4 times [DATE] - 2 times [DATE] - 1 time [DATE] - 5 times [DATE] - 2 times [DATE] - 3 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 1 time [DATE] - 5 times [DATE] - 3 times [DATE] - 2 times No documentation from any staff reporting of CR #1 having wound to his penis and sediments in his urine. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 57 signed indicating she provided care for CR #1 on the following days: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 2:47 p.m. with CNA 57, she was asked about caring for CR #1 again and was shown his picture from his medical record and where she had documented care, including Foley catheter care. She said she recalled care provided saying she never took care of his catheter but could remember feeding him. When asked why did she sign that all care was provided on her on behalf, she replied, that she went around asking other CNA's about their residents things like output and care and entered the information in the kiosk for them in order to keep it from going into red. She said she would go ask the CNA's how much a resident ate and would go report to the nurse if there was a change in condition. She said no one ever told her about a problem with CR #1's catheter or penis but if they did, they were supposed to report it to the nurse. During an interview on [DATE] at 12:50 p.m., the DON she said CR #1 was admitted to the facility with an indwelling catheter but could not remember whether it was changed or not and that best practice should be to document date /time when catheter/bag/ tubing was changed. She also said she did not receive any report and did not hear that he was complaining of pain in his private area. The DON said the implications of not assessing a resident's catheter could be possible retention of urine, and swelling in his pubic area and penis. When asked if staff doing catheter or incontinent care would have seen it if the resident had swelling, sores, and cuts, she said yes, they should have noticed that but if they did not report it nobody would know. Record review of CR #1's shower sheet for [DATE] and [DATE] revealed no documentation of any abnormal finding or wound to the resident's penis. There were no shower sheets for the other days from [DATE] to [DATE]. During a telephone interview on [DATE] at 3:50 p.m. with Physician A, he said he did not receive any calls from the facility regarding sores/cuts or wound on CR #1's penis and he was not notified about his having sediment in his urine. During an interview on [DATE] at 11:55 a.m., the NP for the therapy department said CR #1 had complained to her a couple of times that he was having pain in his privates anytime he saw her and he explained to her that the pain could be from his catheter. The NP said she checked with the nurses and they said he did not complain to them about pain in his catheter or his private area. She also said she had a discussion with the ADON regarding the resident's complaint of pain to his privates and asked for her to look into it and follow up with his Physician. When asked what she would usually do if she had any issues or complaints from any resident, she said she would notify nursing and if the resident's Physician was available, she would mention it to them. She said it was not in her role to assess resident's privates/penis but to notify nursing and she was not sure if he had any problem with his privates or that it was emergent and did not convey it to the ADON as if it was emergent. When asked when she started seeing CR #1, she said from [DATE] to [DATE]. During an interview on [DATE] at 11:25 a.m., the DON when asked whether a staff should document care another person performed, she said that catheter care was done by CNA's and nurses performed care of Suprapubic catheters. She said that whoever did the care should document it and that a CNA should not document care performed by another CNA. Resident #15 Record review of Resident #15's Admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #15's Admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS score of 11 indicating moderately impaired cognition. He was totally dependent on staff for transfers, dressing, eating, toilet use, personal hygiene, and bathing. He needed the extensive assistance of staff with bed mobility. Record review of Resident #15's plan of care dated [DATE] revealed a plan of care for being at risk for complications related to Cardiac Pace Maker in place, at risk for impaired cardiovascular functions, staff assistance for all ADL's, full code, difficulty recalling recent events and use of indwelling suprapubic catheter due to [MEDICAL CONDITION] bladder and at risk for developing Urinary Tract Infections. Record review of Resident #15's Nurses notes for [DATE] revealed documentation of vital signs/status of resident ( per nursing - time reflected was when nurses documented the vitals and not necessarily when the vitals were taken) as follows: --[DATE] at 6:25 a.m. - RN AA documented Resident #15's Temperature 100.5 degrees Fahrenheit, axillary. MD notified, STAT labs and Chest X-ray ordered. --[DATE] at 11:03 a.m. - LVN/Unit Manager (UM) documented that Chest X-ray result revealed left lower lobe increased opacity with consideration for pneumonia, atelectasis and pleural effusion. Notified attending Physician and awaiting response. --[DATE] at 11:21 a.m. - RN AD documented for vital signs taken at 9:00 a:m (per interview with RN AD on [DATE] at 12:20 p.m.): O2 Saturation (SAT) 82% on Room Air (RA), Respiration (Resp) 20, Pulse(P) 123 bpm; resident was put on Oxygen (O2) at 2 liters and Blood Pressure (BP) ,[DATE] mmHg; Physician/Responsible Party (RP) notified. --[DATE] at 11:30 a.m. - RN AD documented she noted the Suprapubic catheter was draining scant urine, MD notified with order to replace catheter, consent obtained from responsible party. --[DATE] at 1:17 p.m. - LVN M documented Resident was difficult to arouse upon verbal and tactile stimuli upon arrival of a visitor. Resp. (respirations) 14 bpm (breathes per minute) , BP (blood pressure) ,[DATE], P (pulse) 62 and no temp. (temperature) and no 02 SAT (oxygen saturation). --[DATE] at 1:32 p.m. - LVN M documented temp. 99 temporal, MD notified and ordered to send Resident #1 out to VA hospital. Contracted Ambulance Response notified at 1:00 p.m. --[DATE] at 2:15 p.m. - LVN M documented - Non rebreather mask applied to resident with O2 (Oxygen) at 15 liters, resident remains stable at this time, 911 arrived at 2:10 p.m., report given, resident still breathing. --[DATE] at 3:00 p.m. - LVN M documented - Addendum: Contracted transport ambulance refused to transport resident due to their assessment of resident which resulted in 911 being called. --[DATE] at 3:31 p.m. - LVN/UM documented a late entry for 2:20 p.m. - 911 in room performing Cardiopulmonary Resuscitation (CPR) on resident starting approximately 2:15 p.m. and [MEDICATION NAME] 15 minutes. Resident left via stretcher escorted by 911 staff. Family members at bedside, attending physician updated. During an interview with Physician #2 on [DATE] at 3:15 p.m. he said that initially he was called about Resident #15 and was told that the resident was not doing well and he ordered some blood work, urine test and chest x-ray. He said he received another call notifying him of the chest x-ray results and that they had not received the results of other blood work. The Physician initially said he believed the staff did what they were supposed to do. He said he talked to the staff at the hospital and they said the resident basically coded. He also said when he spoke with the Medical Examiner he told him he did not need an autopsy and that the body had been released to the funeral home. When asked to explain further, he said that Medical examiners look for wrong doing for an autopsy to be done. When asked if he left any parameters or guidelines as to when to be called he said no and that it was easier to just call him when they have any issues. When asked of the Physician if the facility notified him when Resident #15's O2 SAT dropped to 82% in the morning; when they could not get O2 SAT on him later that morning; when his BP dropped to ,[DATE] and when he became difficult to arouse upon verbal and tactile stimuli, he said he was not notified of those findings and did not know about the situation. When asked what he would have expected the facility to do in those situations, he said he would expect staff to call him immediately. During a confidential interview the person said that they were concerned about the amount of time it took for Resident #15 to receive medical attention including transporting the resident to the hospital. This person raised concerns about the facility in that they failed to call 911 earlier and felt that Resident #15 would still be alive if medical attention needed and transport by 911 were contacted. They said there was confusion during his time of need. He stayed at the facility for two hours instead of being transferred properly. During an interview on [DATE] at 1:45 p.m., LVN M said she was the desk nurse on the date of the incident, [DATE] and that as the desk nurse she was responsible for charting skin assessments, weekly notes, antibiotic charting, and getting paper work ready for resident appointments amongst other tasks. She said she knew what was happening when a visitor came to the desk and said she was Resident #15's visitor and his condition was not good and wanted to know what was happening. She also said RN AD was the floor nurse that had the resident. She further said she went to the room with RN AD to assess the resident and did vital signs on him as follows: BP ,[DATE], P 62, and Resp. ,[DATE] and could not get O2 reading. She said the resident did not respond to his name. She said RN AD left the room and came back and told her the resident was going to be sent out. At about 1:30 p.m. LVN M wrote the transfer order, and prepared transfer papers. She said she did not know what time the transportation was called but noted transport arrived about 1:50 p.m. She said that when transport arrived, they came to the desk and told her they could not transport Resident #15 because they did not have the proper equipment. She called the DON and she said to call 911. When 911 staff came most of the staff went to the room. She said she documented what she was asked to write by LVN/UM. When asked what she should do when a resident had a change in condition, she said assess the resident, obtain vital signs, call the MD, notify DON/RP, and follow MD orders. She said if a resident's condition became worse she would call 911 and notify the MD. LVN M was able to enumerate what to do when she got a new admission including assessment of skin and indwelling catheter - when it was inserted and how urine looks. She said she should get physician's orders [REDACTED]. During an interview on [DATE] at 3:30 p.m., LVN/UM said she was made aware by RN AD that Resident #15 had a temperature of 100.5 degrees Fahrenheit and she gave him Tylenol. She said they document vital signs on their nurse's notes and some on the Medication Administration Record [REDACTED]. She said she was on another hall when she learned about the resident's condition and on getting to the room [ROOM NUMBER] was already there doing CPR. She said the DON with other nurses were in the room. She said she knew the MD was notified of X-ray results but not when his O2 SAT dropped/vital signs. When asked what staff should do when a resident had a change in condition, said they should assess resident including getting vital signs and O2 SAT, call MD and RP and carry out MD orders. She also said others should be documented in the nurse's notes and on their SBAR. She said nurses should not administer medications/treatments without a physician's orders [REDACTED]. During an interview on [DATE] at 5:12 p.m., the DON when asked whether she knew Resident #15 had a change in condition and what happened, she said she knew he had a change in condition and was going to the hospital. She then said she received a call from the nurse that the transport company refused to transport Resident #15 because they could not get an O2 SAT reading on him. She said 911 was already called. She said when she got to the room the resident was still breathing, 911 staff came, checked and obtained his pulse, and then started bagging him and putting in an IV catheter. When the 911 staff came into the room, they intubated him and started CPR. She further said they worked on him for a while before taking him to the ER. When asked whether they should have called 911 instead of the ambulance transport service they use she said the staff had called the ambulance transport service because the resident was clinically stable. She also said when his O2 SAT dropped to 82% Oxygen was applied and he was always having high heart rate even on admission. She said she did not know staff could not get his O2 SAT at 1:17 p.m. as per the nurse's notes and did not know if vital signs were done between the hours of 11:21 a.m. and 1:17 p.m. She said there were many people in the room and thought vital signs were done during that time frame. Requested documentation of the vital signs/monitoring of the resident during the time frame, none was provided provided prior to exit on [DATE]. When the DON was asked if she conducted an investigation regarding the incident, she said yes and she felt anything that needed to be done was done. Surveyor requested for the investigation report. The DON left the room and returned about 10 minutes later and said she did not write the report unless the surveyor wanted her to go and write one then. During a telephone interview on [DATE] at 12:20 p.m., RN AD acknowledged she had Resident #15 on the day shift on [DATE]. She said that when she made rounds that resident was talking and carried on conversation. She said she took the resident's vital signs between 9:00 a.m. and 9:30 a.m. and his O2 SAT was low. She said she notified her supervisor - LVN/UM, put him on O2 at 2 liters and notified Physician #2. She said resident had a temperature and was given Tylenol and Physician #2 was also notified and he ordered Stat laboratory tests, urine tests and x-ray which were performed. When asked why the resident was not monitored including checking his vital signs between when she checked him in the morning at 9:00 or 9:30 a.m. and 1:17 p.m. when the resident's guest notified the desk nurse that the resident was not responding, she said she did vital signs on the resident but did not know the desk nurse did not document the vital signs. She said that after she started Resident #15 on O2, she rechecked his O2 SAT but did not document it and said she remembered mentioning it to somebody but could not remember who at this time. She also said that the resident was monitored but understands that if it was not documented, it was not done. She acknowledged that LVN M notified her that she could not get an O2 SAT on Resident #15 and that was when they decided to send him out. When asked why she did not notify the resident's Physician of the O2 SAT of 82% at about 9:00 a.m., inability to obtain O2 SAT, P 62, Resp. 14 bpm and resident being difficult to arouse by verbal or tactile stimuli documented at 1:17 p.m., she said she thought LVN/UM did. Record review of the contracted Ambulance Transport Run Report Sheet dated [DATE](TRUNCATED)

Based on observation, interview, and record review the facility failed to implement policies and procedures that prohibit neglect for 2 of 18 residents ( CR#1 and Resident #15) reviewed for neglect in that: --The facility failed to ensure CR #1 had physician orders [REDACTED]. --The facility failed to arrange timely emergency transportation on [DATE] at approximately 9:,[DATE]:30 a.m. for Resident #15 when his oxygen saturation dropped to 82%. 911 was not called until 1:00 p.m., approximately 4 hours later. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. These failures affected CR #1 and 1 current resident and placed 11 additional residents in the facility with an indwelling catheter at risk of injury, harm, delayed medical treatment intervention, and possible hospitalization or death. Intake # 7 and # 2 Findings include: Closed Record #1 Record review of CR #1's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was discharged to the hospital on [DATE]. Record review of CR #1's Admission Nurse's notes by LVN U dated [DATE] revealed CR #1 was incontinent of bowel and bladder and there was no documentation of the presence of an indwelling urinary catheter. No other nurses' notes showed he had an indwelling catheter or that the catheter was changed through the time he was discharged . Record review of CR # 1's Admission Clinical Health Status note dated [DATE] documented his elimination and skin condition as follows: --Bladder: Incontinent. There was no documentation of him having an indwelling urinary catheter. The notes documented he was assessed as, incontinent of bowel and bladder. Record review of CR #1's Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 indicating he had severely impaired cognition. He required extensive assistance for dressing, toilet use, and personal hygiene. He required total care with bathing. CR #1 needed supervision for eating and [DIAGNOSES REDACTED]. The MDS did not note the presence of his indwelling urinary catheter. His skin assessment revealed no pressure ulcer but that the resident was at risk of developing pressure ulcers. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed no BIMS score documented. He required extensive assistance for dressing, toilet use, personal hygiene, and total care with bathing. CR #1 needed limited assistance for eating. Assessment of bowel and bladder revealed he was always incontinent of bowel and frequently incontinent of bladder. No skin assessment documented. Record review of Resident # 1's Care Plan for Activities of daily living (ADL) , not dated and not signed, had conflicting interventions. The intervention for bladder function revealed staff to assist resident as needed and record each shift whether he had voided. The same care plan had another intervention that stated resident had urinary catheter and directed staff to provide catheter care and record output. Record review of CR #1's unsigned physician's orders [REDACTED]. There were no admission orders [REDACTED] Record review of CR #1's Medication Admission Record dated July and [DATE] revealed no documented schedule or care for his indwelling urinary catheter. Record review of CR #1's Progress Notes for the month of [DATE] documented by the Nurse Practitioner (NP) for the Therapy department revealed as follows: --[DATE]: He was also complaining about pain in his 'privates.' --[DATE]: He wanted to know who was taking care of his privates now and he was told that the PCP (Primary Care Physician) at Afton was in charge. I discussed his problem with the ADON and she will talk to the patient about his concerns. He stated that other than his pain in his privates he felt ok. --[DATE]: The patient was still complaining about not understanding why he has a problem with his 'privates'. Per nursing, he only seems to complain about the catheter when I am present. Record review of CR#1's clinical record revealed no documentation of follow up care or physician notification. During an interview on [DATE] at 3:23 p.m. with the House Supervisor at the local hospital, she said her concern was that upon admission, CR #1's Foley catheter was dirty, his penis was filleted, it was open and he (Resident # 1) was septic. Record review of CR #1's medical records from the the local hospital obtained on [DATE] revealed he was admitted to the emergency room of the hospital on [DATE] at 13:22 p.m. and upon nursing assessment, it was noted, .Foley in place extremely dirty with sediments all along tube walls, patient's penis is split open from the bottom along the shaft. Urine dark brown It was also documented that CR #1 had [MEDICAL CONDITION] +2 to Right upper arm, right elbow, right forearm, left midcalf, left ankle, left upper arm, left elbow, left forearm, right midcalf and right ankle. Record review of the Physician's Progress Notes from the local hospital dated [DATE] at 9:55 p.m. revealed assessment and plan as follows: --Sepsis secondary to healthcare-associated pneumonia and urinary tract infection secondary to [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) and [MEDICATION NAME]. Urologist consult report from the local hospital dated [DATE] revealed as follows: --the patient noted on a thorough exam by ICU to have an indwelling Foley catheter for unknown reasons and found to have significant traumatic [DIAGNOSES REDACTED] from the Foley catheter. --the patient was previously admitted in the hospital in July and was discharged after a two-week stay to nursing home with a Foley catheter --Foley catheter presumed to be in place for likely [MEDICAL CONDITION] and there was no records found to document whether Foley catheter has been changed or not at the nursing home. The Urologist assessment revealed that the indwelling catheter was in place with approximately 5 cm of traumatic [DIAGNOSES REDACTED] and ventral erosion likely from Foley catheter and stated that the patient needs the Foley catheter to be exchanged and that he could benefit from a suprapubic tube in the future if he desires. Additionally, Nurses Shift Goals- Integumentary from the local hospital documented on [DATE] at 7:00 a.m. noted penile shaft open wound approx. ,[DATE] inch long, monitor s/sx (signs/symptoms) of infection. Observation and interview of CR #1 in his room at the local hospital on [DATE] at 10:59 a.m. with the hospital nurse and social worker present revealed he was alert and oriented to person and place. His right hand was swollen. He answered questions appropriately and coherently. CR #1 said, I will be [AGE] years old and never had something like this happen like this, someone cut it-someone cut it completely open down the shaft . He added the service he received at Afton Oaks was not good. He said, It looks like someone didn't like me, for some reason but I hadn't did anything to anyone, I don't want to go back there, my family member will take me home to (name of home State). CR #1 was in Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his hospital nurse, she said it did not look like his catheter had been taken care of. She said there were old wounds to the front and lateral shaft. She said there was a large laceration on his penis draining pus and the meatus was sliced open, not healed, and with a pink bed to it. Observation of CR #1 in his room at the Medical Center on [DATE] at 8:15 a.m. revealed he was alert and oriented to person and place. His skin was dry with mild swelling to his extremities. He answered questions appropriately and coherently. CR #1 said he was butchered and sore. CR #1 remained on isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his nurse, it was noted that he had a severe cut from the tip of the penis along the shaft and down to the bottom of his penis with an open wound around the shaft and about 80% granulation tissue and 20% slough. He had no Pressure ulcer. CR #1 was still being treated with intravenous and oral antibiotics. The hospital nurse said they were treating the wound with wet to dry dressing changes. During an interview on [DATE] at 4:40 p.m., the Director of Nursing said that CR #1 was admitted into the facility with an indwelling catheter on [DATE]. When asked why his admission MDS assessment did not show documentation of the catheter, she said that she did not know. When asked about CR #1's wound assessment, the DON said his pressure ulcer was a stage 2 on his sacrum. She said that she did the resident's admission skin assessment in the presence of two other staff and that the wound was a stage 2 and it healed within three days. During an interview on [DATE] at 5:24 p.m. with CNA 57 in regards to CR #1 she was asked did she ever provide care for him and she answered, I don't remember, never took care of him. During an interview on [DATE] at 5:45 p.m., the DON said CR #1 was admitted from hospital with the catheter and that it was placed on [DATE] at the hospital. She also said the resident had the catheter placed due to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder. During an interview on [DATE] at 10:13 a.m. with LVN CE, she said in regards to CR #1 he used to sing and everything while doing his care. His right arm was swollen when he came. She said she would help the Treatment Nurse turn him. She said he had a Foley catheter. She said she knew she had taken care of him through the week but could not remember the day. She said his hand was hurting and she gave him a [MEDICATION NAME] and breathing treatment. She said he was sitting up in a chair. She said she could remember that when you got him out of bed, all he wanted to do was go back to bed and he liked to talk. During an interview on [DATE] at 11:00 a.m., the Treatment Nurse (RN AB) said CR #1 had intermittent confusion, his bottom and scrotum were intact. He had a Foley catheter. During an interview on [DATE] at 11:43 a.m. with CNA 31, she said she remembered CR #1. She said she was out for about 6 weeks and returned on the 7th of August. She said CR #1 was a real nice gentleman. She said he started going to the dining room, was taking therapy, and she would give him his showers on Monday, Wednesday and Friday. She said there were no concerns for him. She said he had a little red area on his buttocks and she documented it on the shower sheet and in a couple of days the red area was gone. She said he was incontinent of both bowel and bladder, no Foley or ostomy, but could not really remember. During an interview on [DATE] at 11:51 a.m. with CNA 44, she said that CR #1 was nice, sweet, and that she helped him with everything, he asked, showers, and assist to chair. She said he was incontinent of bowel and bladder and had a urinary catheter. She said there were no problems or skin issues. During an interview on [DATE] at 12:00 p.m., the ADON when asked what she knew about CR #1, she said he was admitted during the middle of July, had an indwelling catheter, and [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. She said the resident was cognitively confused intermittently and complained of pain to the Right shoulder. When asked whether she had any discussion with CR #1's Physician or NP's recently she said not that she could .remember or think of. When asked whether she had discussed with the Nurse Practitioner (NP) with the therapy department she said that Nurse Practitioner (NP) on one occasion said to her in a joking manner something about the resident's catheter and that he, CR #1, said he was going to call an Attorney. She said she did not know what the complaint was about and that it took place about 3 weeks prior. She also said she asked the nurses if CR #1 had complained to them about his catheter and they said no. When asked whether he was being given showers she said she had seen staff take him for showers. A request was made to review the resident's shower sheets from admission to his discharge. When asked if the NP discussed with her the Resident's complaint of pain of his privates she said she never discussed anything about that with her. She also said the resident had never complained to her or the staff about pain to his private area or with the catheter. When asked if she assessed the resident's catheter when the NP notified her of resident's complaints about his catheter, she said that she looked at the drainage bag and tubing and it was clean and she did not check the catheter or his penis because he was sitting in his chair. She said if the NP had told her about pain in the resident's private area she would have assessed the area and would have notified the DON and resident's Physician. During a telephone interview on [DATE] at 12:06 p.m., CNA 16 said that she worked at the facility PRN (as needed) and that she had taken care of CR #1. She said that he had a Foley catheter and sores in his private area, looks like he has a cut down there. When asked if she notified her nurse, she said she did not notify the nurse because the sores and cut looked like they had been there for a long time. She said she would have thought the nurses should have known and that as a PRN staff she had not worked since the last few weeks. She said that while cleaning him she had to be careful because it hurt him. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 16 took care of him on [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. Additionally, record review of the Catheter Output Roster revealed that from [DATE] (admitted ) to [DATE] (discharge date ) staff were documenting that Catheter care was provided each day as follows: [DATE] - 1 time [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 4 times [DATE] - 2 times [DATE] - 1 time [DATE] - 5 times [DATE] - 2 times [DATE] - 3 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 1 time [DATE] - 5 times [DATE] - 3 times [DATE] - 2 times No documentation from any staff reporting of CR #1 having wound to his penis and sediments in his urine. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 57 signed indicating she provided care for CR #1 on the following days: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 2:47 p.m. with CNA 57, she was asked about caring for CR #1 again and was shown his picture from his medical record and where she had documented care, including Foley catheter care. She said she recalled care provided saying she never took care of his catheter but could remember feeding him. When asked why did she sign that all care was provided on her on behalf, she replied, that she went around asking other CNA's about their residents things like output and care and entered the information in the kiosk for them in order to keep it from going into red. She said she would go ask the CNA's how much a resident ate and would go report to the nurse if there was a change in condition. She said no one ever told her about a problem with CR #1's catheter or penis but if they did, they were supposed to report it to the nurse. During an interview on [DATE] at 12:50 p.m., the DON she said CR #1 was admitted to the facility with an indwelling catheter but could not remember whether it was changed or not and that best practice should be to document date /time when catheter/bag/ tubing was changed. She also said she did not receive any report and did not hear that he was complaining of pain in his private area. The DON said the implications of not assessing a resident's catheter could be possible retention of urine, and swelling in his pubic area and penis. When asked if staff doing catheter or incontinent care would have seen it if the resident had swelling, sores, and cuts, she said yes, they should have noticed that but if they did not report it nobody would know. Record review of CR #1's shower sheet for [DATE] and [DATE] revealed no documentation of any abnormal finding or wound to the resident's penis. There were no shower sheets for the other days from [DATE] to [DATE]. During a telephone interview on [DATE] at 3:50 p.m. with Physician A, he said he did not receive any calls from the facility regarding sores/cuts or wound on CR #1's penis and he was not notified about his having sediment in his urine. During an interview on [DATE] at 11:55 a.m., the NP for the therapy department said CR #1 had complained to her a couple of times that he was having pain in his privates anytime he saw her and he explained to her that the pain could be from his catheter. The NP said she checked with the nurses and they said he did not complain to them about pain in his catheter or his private area. She also said she had a discussion with the ADON regarding the resident's complaint of pain to his privates and asked for her to look into it and follow up with his Physician. When asked what she would usually do if she had any issues or complaints from any resident, she said she would notify nursing and if the resident's Physician was available, she would mention it to them. She said it was not in her role to assess resident's privates/penis but to notify nursing and she was not sure if he had any problem with his privates or that it was emergent and did not convey it to the ADON as if it was emergent. When asked when she started seeing CR #1, she said from [DATE] to [DATE]. During an interview on [DATE] at 11:25 a.m., the DON when asked whether a staff should document care another person performed, she said that catheter care was done by CNA's and nurses performed care of Suprapubic catheters. She said that whoever did the care should document it and that a CNA should not document care performed by another CNA. Resident #15 Record review of Resident #15's Admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #15's Admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS score of 11 indicating moderately impaired cognition. He was totally dependent on staff for transfers, dressing, eating, toilet use, personal hygiene, and bathing. He needed the extensive assistance of staff with bed mobility. Record review of Resident #15's plan of care dated [DATE] revealed a plan of care for being at risk for complications related to Cardiac Pace Maker in place, at risk for impaired cardiovascular functions, staff assistance for all ADL's, full code, difficulty recalling recent events and use of indwelling suprapubic catheter due to [MEDICAL CONDITION] bladder and at risk for developing Urinary Tract Infections. Record review of Resident #15's Nurses notes for [DATE] revealed documentation of vital signs/status of resident ( per nursing - time reflected was when nurses documented the vitals and not necessarily when the vitals were taken) as follows: --[DATE] at 6:25 a.m. - RN AA documented Resident #15's Temperature 100.5 degrees Fahrenheit, axillary. MD notified, STAT labs and Chest X-ray ordered. --[DATE] at 11:03 a.m. - LVN/Unit Manager (UM) documented that Chest X-ray result revealed left lower lobe increased opacity with consideration for pneumonia, atelectasis and pleural effusion. Notified attending Physician and awaiting response. --[DATE] at 11:21 a.m. - RN AD documented for vital signs taken at 9:00 a:m (per interview with RN AD on [DATE] at 12:20 p.m.): O2 Saturation (SAT) 82% on Room Air (RA), Respiration (Resp) 20, Pulse(P) 123 bpm; resident was put on Oxygen (O2) at 2 liters and Blood Pressure (BP) ,[DATE] mmHg; Physician/Responsible Party (RP) notified. --[DATE] at 11:30 a.m. - RN AD documented she noted the Suprapubic catheter was draining scant urine, MD notified with order to replace catheter, consent obtained from responsible party. --[DATE] at 1:17 p.m. - LVN M documented Resident was difficult to arouse upon verbal and tactile stimuli upon arrival of a visitor. Resp. (respirations) 14 bpm (breathes per minute) , BP (blood pressure) ,[DATE], P (pulse) 62 and no temp. (temperature) and no 02 SAT (oxygen saturation). --[DATE] at 1:32 p.m. - LVN M documented temp. 99 temporal, MD notified and ordered to send Resident #1 out to VA hospital. Contracted Ambulance Response notified at 1:00 p.m. --[DATE] at 2:15 p.m. - LVN M documented - Non rebreather mask applied to resident with O2 (Oxygen) at 15 liters, resident remains stable at this time, 911 arrived at 2:10 p.m., report given, resident still breathing. --[DATE] at 3:00 p.m. - LVN M documented - Addendum: Contracted transport ambulance refused to transport resident due to their assessment of resident which resulted in 911 being called. --[DATE] at 3:31 p.m. - LVN/UM documented a late entry for 2:20 p.m. - 911 in room performing Cardiopulmonary Resuscitation (CPR) on resident starting approximately 2:15 p.m. and [MEDICATION NAME] 15 minutes. Resident left via stretcher escorted by 911 staff. Family members at bedside, attending physician updated. During an interview with Physician #2 on [DATE] at 3:15 p.m. he said that initially he was called about Resident #15 and was told that the resident was not doing well and he ordered some blood work, urine test and chest x-ray. He said he received another call notifying him of the chest x-ray results and that they had not received the results of other blood work. The Physician initially said he believed the staff did what they were supposed to do. He said he talked to the staff at the hospital and they said the resident basically coded. He also said when he spoke with the Medical Examiner he told him he did not need an autopsy and that the body had been released to the funeral home. When asked to explain further, he said that Medical examiners look for wrong doing for an autopsy to be done. When asked if he left any parameters or guidelines as to when to be called he said no and that it was easier to just call him when they have any issues. When asked of the Physician if the facility notified him when Resident #15's O2 SAT dropped to 82% in the morning; when they could not get O2 SAT on him later that morning; when his BP dropped to ,[DATE] and when he became difficult to arouse upon verbal and tactile stimuli, he said he was not notified of those findings and did not know about the situation. When asked what he would have expected the facility to do in those situations, he said he would expect staff to call him immediately. During a confidential interview the person said that they were concerned about the amount of time it took for Resident #15 to receive medical attention including transporting the resident to the hospital. This person raised concerns about the facility in that they failed to call 911 earlier and felt that Resident #15 would still be alive if medical attention needed and transport by 911 were contacted. They said there was confusion during his time of need. He stayed at the facility for two hours instead of being transferred properly. During an interview on [DATE] at 1:45 p.m., LVN M said she was the desk nurse on the date of the incident, [DATE] and that as the desk nurse she was responsible for charting skin assessments, weekly notes, antibiotic charting, and getting paper work ready for resident appointments amongst other tasks. She said she knew what was happening when a visitor came to the desk and said she was Resident #15's visitor and his condition was not good and wanted to know what was happening. She also said RN AD was the floor nurse that had the resident. She further said she went to the room with RN AD to assess the resident and did vital signs on him as follows: BP ,[DATE], P 62, and Resp. ,[DATE] and could not get O2 reading. She said the resident did not respond to his name. She said RN AD left the room and came back and told her the resident was going to be sent out. At about 1:30 p.m. LVN M wrote the transfer order, and prepared transfer papers. She said she did not know what time the transportation was called but noted transport arrived about 1:50 p.m. She said that when transport arrived, they came to the desk and told her they could not transport Resident #15 because they did not have the proper equipment. She called the DON and she said to call 911. When 911 staff came most of the staff went to the room. She said she documented what she was asked to write by LVN/UM. When asked what she should do when a resident had a change in condition, she said assess the resident, obtain vital signs, call the MD, notify DON/RP, and follow MD orders. She said if a resident's condition became worse she would call 911 and notify the MD. LVN M was able to enumerate what to do when she got a new admission including assessment of skin and indwelling catheter - when it was inserted and how urine looks. She said she should get physician's orders [REDACTED]. During an interview on [DATE] at 3:30 p.m., LVN/UM said she was made aware by RN AD that Resident #15 had a temperature of 100.5 degrees Fahrenheit and she gave him Tylenol. She said they document vital signs on their nurse's notes and some on the Medication Administration Record [REDACTED]. She said she was on another hall when she learned about the resident's condition and on getting to the room [ROOM NUMBER] was already there doing CPR. She said the DON with other nurses were in the room. She said she knew the MD was notified of X-ray results but not when his O2 SAT dropped/vital signs. When asked what staff should do when a resident had a change in condition, said they should assess resident including getting vital signs and O2 SAT, call MD and RP and carry out MD orders. She also said others should be documented in the nurse's notes and on their SBAR. She said nurses should not administer medications/treatments without a physician's orders [REDACTED]. During an interview on [DATE] at 5:12 p.m., the DON when asked whether she knew Resident #15 had a change in condition and what happened, she said she knew he had a change in condition and was going to the hospital. She then said she received a call from the nurse that the transport company refused to transport Resident #15 because they could not get an O2 SAT reading on him. She said 911 was already called. She said when she got to the room the resident was still breathing, 911 staff came, checked and obtained his pulse, and then started bagging him and putting in an IV catheter. When the 911 staff came into the room, they intubated him and started CPR. She further said they worked on him for a while before taking him to the ER. When asked whether they should have called 911 instead of the ambulance transport service they use she said the staff had called the ambulance transport service because the resident was clinically stable. She also said when his O2 SAT dropped to 82% Oxygen was applied and he was always having high heart rate even on admission. She said she did not know staff could not get his O2 SAT at 1:17 p.m. as per the nurse's notes and did not know if vital signs were done between the hours of 11:21 a.m. and 1:17 p.m. She said there were many people in the room and thought vital signs were done during that time frame. Requested documentation of the vital signs/monitoring of the resident during the time frame, none was provided provided prior to exit on [DATE]. When the DON was asked if she conducted an investigation regarding the incident, she said yes and she felt anything that needed to be done was done. Surveyor requested for the investigation report. The DON left the room and returned about 10 minutes later and said she did not write the report unless the surveyor wanted her to go and write one then. During an interview on [DATE] at 10:00 a.m., the DON when asked who was responsible for making decisions as to whether to call 911 or call their contracted Ambulance service she said the Charge Nurse was the person to make the decision. If the condition worsened, the nurses could make the decisions and then notify her. She said she could update or change the decision if she was available. When asked if Resident #15's Physician had parameters or guidelines as to when staff should call him, she said no that only Resident #1's Physician had parameters. During an interview with the contracted ambulance transport dispatcher on [DATE] at 11:13 a.m., he said he received the call from Afton Oaks around 1:00 p.m. and when he asked the nurse the resident's status, she said Altered Mental Status and that it took staff about ½ hour to get to the facility. He said the staff that went to the facility said upon arrival, the nurse said the resident just got sick. They said that when they got to the room, the resident was breathing but they could not get his Oxygen Saturation on him with their machine. So, they advised them to call 911 and left. Requested for a copy of their run sheet. He said he would fax it. During a telephone interview on [DATE] at 12:20 p.m., RN AD acknowledged she had Resident #15 on the day shift on [DATE]. She said that when she made rounds that resident was talking and carried on conversation. She said she took the resident's vital signs between 9:00 a.m. and 9:30 a.m. and his O2 SAT was low. She said she notified her supervisor - LVN/UM, put him on O2 at 2 liters and notified Physician #2. She said resident had a temperature and was given Tylenol and Physician #2 was also notified and he ordered Stat laboratory tests, urine tests and x-ray which were performed. When asked why the resident was not monitored including checking his vital signs between when she (TRUNCATED)

Based on observation, interview and record review, the facility failed to provide services that meet professional standards of quality for 2 of 18 residents (CR#1 and #15) reviewed for professional standards in that: --The facility failed to ensure CR #1 had physician orders [REDACTED]. --The facility failed to arrange timely emergency transportation on [DATE] at approximately 9:,[DATE]:30 a.m. for Resident #15 when his oxygen saturation dropped to 82%. 911 was not called until 1:00 p.m., approximately 4 hours later. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 1 hospitalized and 1 current resident and placed 11 additional residents in the facility with an indwelling catheter at risk of injury, harm, delayed medical treatment intervention, and possible hospitalization or death. Intake # 7 and # 2 Findings include: Record review of the Texas Administrative Code, Title 22, Part 11, Chapter 217 of the Texas Board of Nursing revealed in part: .The unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify unprofessional or dishonorable behaviors of a nurse which the board believes are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: . (6) Misconduct--actions or conduct that include, but are not limited to: .(C) Causing or permitting physical, emotional or verbal abuse or injury or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority and/or licensing board; . Closed Record #1 Record review of CR #1's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was discharged to the hospital on [DATE]. Record review of CR #1's Admission Nurse's notes by LVN U dated [DATE] revealed CR #1 was incontinent of bowel and bladder and there was no documentation of the presence of an indwelling urinary catheter. No other nurses' notes showed he had an indwelling catheter or that the catheter was changed through the time he was discharged . Record review of CR # 1's Admission Clinical Health Status note dated [DATE] documented his elimination and skin condition as follows: --Bladder: Incontinent. There was no documentation of him having an indwelling urinary catheter. The notes documented he was assessed as, incontinent of bowel and bladder. Record review of CR #1's Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 indicating he had severely impaired cognition. He required extensive assistance for dressing, toilet use, and personal hygiene. He required total care with bathing. CR #1 needed supervision for eating and [DIAGNOSES REDACTED]. The MDS did not note the presence of his indwelling urinary catheter. His skin assessment revealed no pressure ulcer but that the resident was at risk of developing pressure ulcers. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed no BIMS score documented. He required extensive assistance for dressing, toilet use, personal hygiene, and total care with bathing. CR #1 needed limited assistance for eating. Assessment of bowel and bladder revealed he was always incontinent of bowel and frequently incontinent of bladder. No skin assessment documented. Record review of Resident # 1's Care Plan for Activities of daily living (ADL) , not dated and not signed, had conflicting interventions. The intervention for bladder function revealed staff to assist resident as needed and record each shift whether he had voided. The same care plan had another intervention that stated resident had urinary catheter and directed staff to provide catheter care and record output. Record review of CR #1's unsigned physician's orders [REDACTED]. There were no admission orders [REDACTED] Record review of CR #1's Medication Admission Record dated July and [DATE] revealed no documented schedule or care for his indwelling urinary catheter. Record review of CR #1's Progress Notes for the month of [DATE] documented by the Nurse Practitioner (NP) for the Therapy department revealed as follows: --[DATE]: He was also complaining about pain in his 'privates.' --[DATE]: He wanted to know who was taking care of his privates now and he was told that the PCP (Primary Care Physician) at Afton was in charge. I discussed his problem with the ADON and she will talk to the patient about his concerns. He stated that other than his pain in his privates he felt ok. --[DATE]: The patient was still complaining about not understanding why he has a problem with his 'privates'. Per nursing, he only seems to complain about the catheter when I am present. Record review of CR#1's clinical record revealed no documentation of follow up care or physician notification. During an interview on [DATE] at 3:23 p.m. with the House Supervisor at the local hospital, she said her concern was that upon admission, CR #1's Foley catheter was dirty, his penis was filleted, it was open and he (Resident # 1) was septic. Record review of CR #1's medical records from the the local hospital obtained on [DATE] revealed he was admitted to the emergency room of the hospital on [DATE] at 13:22 p.m. and upon nursing assessment, it was noted, .Foley in place extremely dirty with sediments all along tube walls, patient's penis is split open from the bottom along the shaft. Urine dark brown It was also documented that CR #1 had [MEDICAL CONDITION] +2 to Right upper arm, right elbow, right forearm, left midcalf, left ankle, left upper arm, left elbow, left forearm, right midcalf and right ankle. Record review of the Physician's Progress Notes from the local hospital dated [DATE] at 9:55 p.m. revealed assessment and plan as follows: --Sepsis secondary to healthcare-associated pneumonia and urinary tract infection secondary to [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) and [MEDICATION NAME]. Urologist consult report from the local hospital dated [DATE] revealed as follows: --the patient noted on a thorough exam by ICU to have an indwelling Foley catheter for unknown reasons and found to have significant traumatic [DIAGNOSES REDACTED] from the Foley catheter. --the patient was previously admitted in the hospital in July and was discharged after a two-week stay to nursing home with a Foley catheter --Foley catheter presumed to be in place for likely [MEDICAL CONDITION] and there was no records found to document whether Foley catheter has been changed or not at the nursing home. The Urologist assessment revealed that the indwelling catheter was in place with approximately 5 cm of traumatic [DIAGNOSES REDACTED] and ventral erosion likely from Foley catheter and stated that the patient needs the Foley catheter to be exchanged and that he could benefit from a suprapubic tube in the future if he desires. Additionally, Nurses Shift Goals- Integumentary from the local hospital documented on [DATE] at 7:00 a.m. noted penile shaft open wound approx. ,[DATE] inch long, monitor s/sx (signs/symptoms) of infection. Observation and interview of CR #1 in his room at the local hospital on [DATE] at 10:59 a.m. with the hospital nurse and social worker present revealed he was alert and oriented to person and place. His right hand was swollen. He answered questions appropriately and coherently. CR #1 said, I will be [AGE] years old and never had something like this happen like this, someone cut it-someone cut it completely open down the shaft . He added the service he received at Afton Oaks was not good. He said, It looks like someone didn't like me, for some reason but I hadn't did anything to anyone, I don't want to go back there, my family member will take me home to (name of home State). CR #1 was in Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his hospital nurse, she said it did not look like his catheter had been taken care of. She said there were old wounds to the front and lateral shaft. She said there was a large laceration on his penis draining pus and the meatus was sliced open, not healed, and with a pink bed to it. Observation of CR #1 in his room at the Medical Center on [DATE] at 8:15 a.m. revealed he was alert and oriented to person and place. His skin was dry with mild swelling to his extremities. He answered questions appropriately and coherently. CR #1 said he was butchered and sore. CR #1 remained on isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his nurse, it was noted that he had a severe cut from the tip of the penis along the shaft and down to the bottom of his penis with an open wound around the shaft and about 80% granulation tissue and 20% slough. He had no Pressure ulcer. CR #1 was still being treated with intravenous and oral antibiotics. The hospital nurse said they were treating the wound with wet to dry dressing changes. During an interview on [DATE] at 4:40 p.m., the Director of Nursing said that CR #1 was admitted into the facility with an indwelling catheter on [DATE]. When asked why his admission MDS assessment did not show documentation of the catheter, she said that she did not know. When asked about CR #1's wound assessment, the DON said his pressure ulcer was a stage 2 on his sacrum. She said that she did the resident's admission skin assessment in the presence of two other staff and that the wound was a stage 2 and it healed within three days. During an interview on [DATE] at 5:24 p.m. with CNA 57 in regards to CR #1 she was asked did she ever provide care for him and she answered, I don't remember, never took care of him. During an interview on [DATE] at 5:45 p.m., the DON said CR #1 was admitted from hospital with the catheter and that it was placed on [DATE] at the hospital. She also said the resident had the catheter placed due to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder. During an interview on [DATE] at 10:13 a.m. with LVN CE, she said in regards to CR #1 he used to sing and everything while doing his care. His right arm was swollen when he came. She said she would help the Treatment Nurse turn him. She said he had a Foley catheter. She said she knew she had taken care of him through the week but could not remember the day. She said his hand was hurting and she gave him a [MEDICATION NAME] and breathing treatment. She said he was sitting up in a chair. She said she could remember that when you got him out of bed, all he wanted to do was go back to bed and he liked to talk. During an interview on [DATE] at 11:00 a.m., the Treatment Nurse (RN AB) said CR #1 had intermittent confusion, his bottom and scrotum were intact. He had a Foley catheter. During an interview on [DATE] at 11:43 a.m. with CNA 31, she said she remembered CR #1. She said she was out for about 6 weeks and returned on the 7th of August. She said CR #1 was a real nice gentleman. She said he started going to the dining room, was taking therapy, and she would give him his showers on Monday, Wednesday and Friday. She said there were no concerns for him. She said he had a little red area on his buttocks and she documented it on the shower sheet and in a couple of days the red area was gone. She said he was incontinent of both bowel and bladder, no Foley or ostomy, but could not really remember. During an interview on [DATE] at 11:51 a.m. with CNA 44, she said that CR #1 was nice, sweet, and that she helped him with everything, he asked, showers, and assist to chair. She said he was incontinent of bowel and bladder and had a urinary catheter. She said there were no problems or skin issues. During an interview on [DATE] at 12:00 p.m., the ADON when asked what she knew about CR #1, she said he was admitted during the middle of July, had an indwelling catheter, and [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. She said the resident was cognitively confused intermittently and complained of pain to the Right shoulder. When asked whether she had any discussion with CR #1's Physician or NP's recently she said not that she could .remember or think of. When asked whether she had discussed with the Nurse Practitioner (NP) with the therapy department she said that Nurse Practitioner (NP) on one occasion said to her in a joking manner something about the resident's catheter and that he, CR #1, said he was going to call an Attorney. She said she did not know what the complaint was about and that it took place about 3 weeks prior. She also said she asked the nurses if CR #1 had complained to them about his catheter and they said no. When asked whether he was being given showers she said she had seen staff take him for showers. A request was made to review the resident's shower sheets from admission to his discharge. When asked if the NP discussed with her the Resident's complaint of pain of his privates she said she never discussed anything about that with her. She also said the resident had never complained to her or the staff about pain to his private area or with the catheter. When asked if she assessed the resident's catheter when the NP notified her of resident's complaints about his catheter, she said that she looked at the drainage bag and tubing and it was clean and she did not check the catheter or his penis because he was sitting in his chair. She said if the NP had told her about pain in the resident's private area she would have assessed the area and would have notified the DON and resident's Physician. During a telephone interview on [DATE] at 12:06 p.m., CNA 16 said that she worked at the facility PRN (as needed) and that she had taken care of CR #1. She said that he had a Foley catheter and sores in his private area, looks like he has a cut down there. When asked if she notified her nurse, she said she did not notify the nurse because the sores and cut looked like they had been there for a long time. She said she would have thought the nurses should have known and that as a PRN staff she had not worked since the last few weeks. She said that while cleaning him she had to be careful because it hurt him. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 16 took care of him on [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. Additionally, record review of the Catheter Output Roster revealed that from [DATE] (admitted ) to [DATE] (discharge date ) staff were documenting that Catheter care was provided each day as follows: [DATE] - 1 time [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 4 times [DATE] - 2 times [DATE] - 1 time [DATE] - 5 times [DATE] - 2 times [DATE] - 3 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 1 time [DATE] - 5 times [DATE] - 3 times [DATE] - 2 times No documentation from any staff reporting of CR #1 having wound to his penis and sediments in his urine. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 57 signed indicating she provided care for CR #1 on the following days: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 2:47 p.m. with CNA 57, she was asked about caring for CR #1 again and was shown his picture from his medical record and where she had documented care, including Foley catheter care. She said she recalled care provided saying she never took care of his catheter but could remember feeding him. When asked why did she sign that all care was provided on her on behalf, she replied, that she went around asking other CNA's about their residents things like output and care and entered the information in the kiosk for them in order to keep it from going into red. She said she would go ask the CNA's how much a resident ate and would go report to the nurse if there was a change in condition. She said no one ever told her about a problem with CR #1's catheter or penis but if they did, they were supposed to report it to the nurse. During an interview on [DATE] at 12:50 p.m., the DON she said CR #1 was admitted to the facility with an indwelling catheter but could not remember whether it was changed or not and that best practice should be to document date /time when catheter/bag/ tubing was changed. She also said she did not receive any report and did not hear that he was complaining of pain in his private area. The DON said the implications of not assessing a resident's catheter could be possible retention of urine, and swelling in his pubic area and penis. When asked if staff doing catheter or incontinent care would have seen it if the resident had swelling, sores, and cuts, she said yes, they should have noticed that but if they did not report it nobody would know. Record review of CR #1's shower sheet for [DATE] and [DATE] revealed no documentation of any abnormal finding or wound to the resident's penis. There were no shower sheets for the other days from [DATE] to [DATE]. During a telephone interview on [DATE] at 3:50 p.m. with Physician A, he said he did not receive any calls from the facility regarding sores/cuts or wound on CR #1's penis and he was not notified about his having sediment in his urine. During an interview on [DATE] at 11:55 a.m., the NP for the therapy department said CR #1 had complained to her a couple of times that he was having pain in his privates anytime he saw her and he explained to her that the pain could be from his catheter. The NP said she checked with the nurses and they said he did not complain to them about pain in his catheter or his private area. She also said she had a discussion with the ADON regarding the resident's complaint of pain to his privates and asked for her to look into it and follow up with his Physician. When asked what she would usually do if she had any issues or complaints from any resident, she said she would notify nursing and if the resident's Physician was available, she would mention it to them. She said it was not in her role to assess resident's privates/penis but to notify nursing and she was not sure if he had any problem with his privates or that it was emergent and did not convey it to the ADON as if it was emergent. When asked when she started seeing CR #1, she said from [DATE] to [DATE]. During an interview on [DATE] at 11:25 a.m., the DON when asked whether a staff should document care another person performed, she said that catheter care was done by CNA's and nurses performed care of Suprapubic catheters. She said that whoever did the care should document it and that a CNA should not document care performed by another CNA. Resident #15 Record review of Resident #15's Admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #15's Admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS score of 11 indicating moderately impaired cognition. He was totally dependent on staff for transfers, dressing, eating, toilet use, personal hygiene, and bathing. He needed the extensive assistance of staff with bed mobility. Record review of Resident #15's plan of care dated [DATE] revealed a plan of care for being at risk for complications related to Cardiac Pace Maker in place, at risk for impaired cardiovascular functions, staff assistance for all ADL's, full code, difficulty recalling recent events and use of indwelling suprapubic catheter due to [MEDICAL CONDITION] bladder and at risk for developing Urinary Tract Infections. Record review of Resident #15's Nurses notes for [DATE] revealed documentation of vital signs/status of resident ( per nursing - time reflected was when nurses documented the vitals and not necessarily when the vitals were taken) as follows: --[DATE] at 6:25 a.m. - RN AA documented Resident #15's Temperature 100.5 degrees Fahrenheit, axillary. MD notified, STAT labs and Chest X-ray ordered. --[DATE] at 11:03 a.m. - LVN/Unit Manager (UM) documented that Chest X-ray result revealed left lower lobe increased opacity with consideration for pneumonia, atelectasis and pleural effusion. Notified attending Physician and awaiting response. --[DATE] at 11:21 a.m. - RN AD documented for vital signs taken at 9:00 a:m (per interview with RN AD on [DATE] at 12:20 p.m.): O2 Saturation (SAT) 82% on Room Air (RA), Respiration (Resp) 20, Pulse(P) 123 bpm; resident was put on Oxygen (O2) at 2 liters and Blood Pressure (BP) ,[DATE] mmHg; Physician/Responsible Party (RP) notified. --[DATE] at 11:30 a.m. - RN AD documented she noted the Suprapubic catheter was draining scant urine, MD notified with order to replace catheter, consent obtained from responsible party. --[DATE] at 1:17 p.m. - LVN M documented Resident was difficult to arouse upon verbal and tactile stimuli upon arrival of a visitor. Resp. (respirations) 14 bpm (breathes per minute) , BP (blood pressure) ,[DATE], P (pulse) 62 and no temp. (temperature) and no 02 SAT (oxygen saturation). --[DATE] at 1:32 p.m. - LVN M documented temp. 99 temporal, MD notified and ordered to send Resident #1 out to VA hospital. Contracted Ambulance Response notified at 1:00 p.m. --[DATE] at 2:15 p.m. - LVN M documented - Non rebreather mask applied to resident with O2 (Oxygen) at 15 liters, resident remains stable at this time, 911 arrived at 2:10 p.m., report given, resident still breathing. --[DATE] at 3:00 p.m. - LVN M documented - Addendum: Contracted transport ambulance refused to transport resident due to their assessment of resident which resulted in 911 being called. --[DATE] at 3:31 p.m. - LVN/UM documented a late entry for 2:20 p.m. - 911 in room performing Cardiopulmonary Resuscitation (CPR) on resident starting approximately 2:15 p.m. and [MEDICATION NAME] 15 minutes. Resident left via stretcher escorted by 911 staff. Family members at bedside, attending physician updated. During an interview with Physician #2 on [DATE] at 3:15 p.m. he said that initially he was called about Resident #15 and was told that the resident was not doing well and he ordered some blood work, urine test and chest x-ray. He said he received another call notifying him of the chest x-ray results and that they had not received the results of other blood work. The Physician initially said he believed the staff did what they were supposed to do. He said he talked to the staff at the hospital and they said the resident basically coded. He also said when he spoke with the Medical Examiner he told him he did not need an autopsy and that the body had been released to the funeral home. When asked to explain further, he said that Medical examiners look for wrong doing for an autopsy to be done. When asked if he left any parameters or guidelines as to when to be called he said no and that it was easier to just call him when they have any issues. When asked of the Physician if the facility notified him when Resident #15's O2 SAT dropped to 82% in the morning; when they could not get O2 SAT on him later that morning; when his BP dropped to ,[DATE] and when he became difficult to arouse upon verbal and tactile stimuli, he said he was not notified of those findings and did not know about the situation. When asked what he would have expected the facility to do in those situations, he said he would expect staff to call him immediately. During a confidential interview the person said that they were concerned about the amount of time it took for Resident #15 to receive medical attention including transporting the resident to the hospital. This person raised concerns about the facility in that they failed to call 911 earlier and felt that Resident #15 would still be alive if medical attention needed and transport by 911 were contacted. They said there was confusion during his time of need. He stayed at the facility for two hours instead of being transferred properly. During an interview on [DATE] at 1:45 p.m., LVN M said she was the desk nurse on the date of the incident, [DATE] and that as the desk nurse she was responsible for charting skin assessments, weekly notes, antibiotic charting, and getting paper work ready for resident appointments amongst other tasks. She said she knew what was happening when a visitor came to the desk and said she was Resident #15's visitor and his condition was not good and wanted to know what was happening. She also said RN AD was the floor nurse that had the resident. She further said she went to the room with RN AD to assess the resident and did vital signs on him as follows: BP ,[DATE], P 62, and Resp. ,[DATE] and could not get O2 reading. She said the resident did not respond to his name. She said RN AD left the room and came back and told her the resident was going to be sent out. At about 1:30 p.m. LVN M wrote the transfer order, and prepared transfer papers. She said she did not know what time the transportation was called but noted transport arrived about 1:50 p.m. She said that when transport arrived, they came to the desk and told her they could not transport Resident #15 because they did not have the proper equipment. She called the DON and she said to call 911. When 911 staff came most of the staff went to the room. She said she documented what she was asked to write by LVN/UM. When asked what she should do when a resident had a change in condition, she said assess the resident, obtain vital signs, call the MD, notify DON/RP, and follow MD orders. She said if a resident's condition became worse she would call 911 and notify the MD. LVN M was able to enumerate what to do when she got a new admission including assessment of skin and indwelling catheter - when it was inserted and how urine looks. She said she should get physician's orders [REDACTED]. During an interview on [DATE] at 3:30 p.m., LVN/UM said she was made aware by RN AD that Resident #15 had a temperature of 100.5 degrees Fahrenheit and she gave him Tylenol. She said they document vital signs on their nurse's notes and some on the Medication Administration Record [REDACTED]. She said she was on another hall when she learned about the resident's condition and on getting to the room [ROOM NUMBER] was already there doing CPR. She said the DON with other nurses were in the room. She said she knew the MD was notified of X-ray results but not when his O2 SAT dropped/vital signs. When asked what staff should do when a resident had a change in condition, said they should assess resident including getting vital signs and O2 SAT, call MD and RP and carry out MD orders. She also said others should be documented in the nurse's notes and on their SBAR. She said nurses should not administer medications/treatments without a physician's orders [REDACTED]. During an interview on [DATE] at 5:12 p.m., the DON when asked whether she knew Resident #15 had a change in condition and what happened, she said she knew he had a change in condition and was going to the hospital. She then said she received a call from the nurse that the transport company refused to transport Resident #15 because they could not get an O2 SAT reading on him. She said 911 was already called. She said when she got to the room the resident was still breathing, 911 staff came, checked and obtained his pulse, and then started bagging him and putting in an IV catheter. When the 911 staff came into the room, they intubated him and started CPR. She further said they worked on him for a while before taking him to the ER. When asked whether they should have called 911 instead of the ambulance transport service they use she said the staff had called the ambulance transport service because the resident was clinically stable. She also said when his O2 SAT dropped to 82% Oxygen was applied and he was always having high heart rate even on admission. She said she did not know staff could not get his O2 SAT at 1:17 p.m. as per the nurse's notes and did not know if vital signs were done between the hours of 11:21 a.m. and 1:17 p.m. She said there were many people in the room and thought vital signs were done during that time frame. Requested documentation of the vital signs/monitoring of the resident during the time frame, none was provided provided prior to exit on [DATE]. When the DON was asked if she conducted an investigation regarding the incident, she said yes and she felt anything that needed to be done was done. Surveyor requested for the investigation report. The DON left the room and returned about 10 minutes later and said she did not write the report unless the surveyor wanted her to go and write one then. During an interview on [DATE] at 10:00 a.m., the DON when asked who was responsible for making decisions as to whether to call 911 or call their contracted Ambulance service she said the Charge Nurse was the person to make the decision. If the condition worsened, the nurses could make the decisions and then notify her. She said she could update or change the decision if she was available. When asked if Resident #15's Physician had parameters or guidelines as to when staff should call him, she said no that only Resident #1's Physician had parameters. During an interview with the contracted ambulance transport dispatcher on [DATE] at 11:13 a.m., he said he received the call from Afton Oaks around 1:00 p.m. and when he asked the nurse the resident's status, she said Altered Mental Status and that it took staff about ½ hour to get to the facility. He said the staff that went to the facility said upon arrival, the nurse said the resident just got sick. They said that when they got to the room, the resident was breathing but they could not get his Oxygen Saturation on him

Based on observation, record review, and interview, the administration failed to administer the facility in a manner that enabled it to use the facility's resources effectively to maintain the highest practicable physical wellbeing of 2 of 18 residents (CR #1 and Resident #15) who were reviewed for administration of care in that: --The Administrator failed to effectively implement policies and procedures rearding abuse and neglect. --The Administrator failed to supervise the DON on training and monitoring nursing staff regarding assessment, monitoring and promptly consulting physicians concerning changes in condition. --The DON failed to train CNAs on notifying licensed staff on changes in condition. An immediate jeopardy (IJ) was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate jeopardy. The facility needed additional time to monitor and evaluate the effectiveness of their plan. This failure affected 1 hospitalized resident and 1 current resident and placed 11 other residents in the facility with indwelling urinary catheters at risk of injury, harm, urinary tract infections, hospitalization , and possible death. Intake # 7 and 2 Findings include: On [DATE] at 3:36 p.m. an interview with the Administrator when asked how he monitored to ensure the DON was performing her duties, his response was that he has the following procedures to make sure residents needs are met, the morning meeting, stand-up clinical, the 24 hour report and significant change of condition-ongoing, onset acute, then go into rehab to see if residents are progressing or not. He said they have QAPI to make sure things are going, management by walking around and having questions to all staff, this facility has a lot of RN's on staff because of their scope of knowledge from a quality point of view and in-services are ongoing. On [DATE] at 2:10 p.m. an interview with the DON revealed the following: when asked what type of training did you ensure the nurses had in order to care for residents, she said change in condition, pain, Foley care, abnormalities, transferring residents out of the facility, abuse/neglect, skin and sediments in catheters. When asked how did she think this IJ (immediate jeopardy came about, she said communication-verbally and written was dropped. She said to assure that job duties are being performed she will go behind staff to make sure the job is being done, if she notices any issues are there, they will re-educate to make sure training is effective, including demonstration and return demonstration with indescrepancies. Closed Record #1 Record review of CR #1's admission record revealed he was [AGE] years old and was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. He was discharged to the hospital on [DATE]. Record review of CR #1's Admission Nurse's notes by LVN U dated [DATE] revealed CR #1 was incontinent of bowel and bladder and there was no documentation of the presence of an indwelling urinary catheter. No other nurses' notes showed he had an indwelling catheter or that the catheter was changed through the time he was discharged . Record review of CR # 1's Admission Clinical Health Status note dated [DATE] documented his elimination and skin condition as follows: --Bladder: Incontinent. There was no documentation of him having an indwelling urinary catheter. The notes documented he was assessed as, incontinent of bowel and bladder. Record review of CR #1's Admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 5 indicating he had severely impaired cognition. He required extensive assistance for dressing, toilet use, and personal hygiene. He required total care with bathing. CR #1 needed supervision for eating and [DIAGNOSES REDACTED]. The MDS did not note the presence of his indwelling urinary catheter. His skin assessment revealed no pressure ulcer but that the resident was at risk of developing pressure ulcers. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed no BIMS score documented. He required extensive assistance for dressing, toilet use, personal hygiene, and total care with bathing. CR #1 needed limited assistance for eating. Assessment of bowel and bladder revealed he was always incontinent of bowel and frequently incontinent of bladder. No skin assessment documented. Record review of Resident # 1's Care Plan for Activities of daily living (ADL) , not dated and not signed, had conflicting interventions. The intervention for bladder function revealed staff to assist resident as needed and record each shift whether he had voided. The same care plan had another intervention that stated resident had urinary catheter and directed staff to provide catheter care and record output. Record review of CR #1's unsigned physician's orders [REDACTED]. There were no admission orders [REDACTED] Record review of CR #1's Medication Admission Record dated July and [DATE] revealed no documented schedule or care for his indwelling urinary catheter. Record review of CR #1's Progress Notes for the month of [DATE] documented by the Nurse Practitioner (NP) for the Therapy department revealed as follows: --[DATE]: He was also complaining about pain in his 'privates.' --[DATE]: He wanted to know who was taking care of his privates now and he was told that the PCP (Primary Care Physician) at Afton was in charge. I discussed his problem with the ADON and she will talk to the patient about his concerns. He stated that other than his pain in his privates he felt ok. --[DATE]: The patient was still complaining about not understanding why he has a problem with his 'privates'. Per nursing, he only seems to complain about the catheter when I am present. Record review of CR#1's clinical record revealed no documentation of follow up care or physician notification. During an interview on [DATE] at 3:23 p.m. with the House Supervisor at the local hospital, she said her concern was that upon admission, CR #1's Foley catheter was dirty, his penis was filleted, it was open and he (Resident # 1) was septic. Record review of CR #1's medical records from the the local hospital obtained on [DATE] revealed he was admitted to the emergency room of the hospital on [DATE] at 13:22 p.m. and upon nursing assessment, it was noted, .Foley in place extremely dirty with sediments all along tube walls, patient's penis is split open from the bottom along the shaft. Urine dark brown It was also documented that CR #1 had [MEDICAL CONDITION] +2 to Right upper arm, right elbow, right forearm, left midcalf, left ankle, left upper arm, left elbow, left forearm, right midcalf and right ankle. Record review of the Physician's Progress Notes from the local hospital dated [DATE] at 9:55 p.m. revealed assessment and plan as follows: --Sepsis secondary to healthcare-associated pneumonia and urinary tract infection secondary to [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) and [MEDICATION NAME]. Urologist consult report from the local hospital dated [DATE] revealed as follows: --the patient noted on a thorough exam by ICU to have an indwelling Foley catheter for unknown reasons and found to have significant traumatic [DIAGNOSES REDACTED] from the Foley catheter. --the patient was previously admitted in the hospital in July and was discharged after a two-week stay to nursing home with a Foley catheter --Foley catheter presumed to be in place for likely [MEDICAL CONDITION] and there was no records found to document whether Foley catheter has been changed or not at the nursing home. The Urologist assessment revealed that the indwelling catheter was in place with approximately 5 cm of traumatic [DIAGNOSES REDACTED] and ventral erosion likely from Foley catheter and stated that the patient needs the Foley catheter to be exchanged and that he could benefit from a suprapubic tube in the future if he desires. Additionally, Nurses Shift Goals- Integumentary from the local hospital documented on [DATE] at 7:00 a.m. noted penile shaft open wound approx. ,[DATE] inch long, monitor s/sx (signs/symptoms) of infection. Observation and interview of CR #1 in his room at the local hospital on [DATE] at 10:59 a.m. with the hospital nurse and social worker present revealed he was alert and oriented to person and place. His right hand was swollen. He answered questions appropriately and coherently. CR #1 said, I will be [AGE] years old and never had something like this happen like this, someone cut it-someone cut it completely open down the shaft . He added the service he received at Afton Oaks was not good. He said, It looks like someone didn't like me, for some reason but I hadn't did anything to anyone, I don't want to go back there, my family member will take me home to (name of home State). CR #1 was in Isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his hospital nurse, she said it did not look like his catheter had been taken care of. She said there were old wounds to the front and lateral shaft. She said there was a large laceration on his penis draining pus and the meatus was sliced open, not healed, and with a pink bed to it. Observation of CR #1 in his room at the Medical Center on [DATE] at 8:15 a.m. revealed he was alert and oriented to person and place. His skin was dry with mild swelling to his extremities. He answered questions appropriately and coherently. CR #1 said he was butchered and sore. CR #1 remained on isolation for [MEDICAL CONDITION]-resistant staphylococcus aureus (MRSA) in his urine and [MEDICATION NAME]. Upon assessment by his nurse, it was noted that he had a severe cut from the tip of the penis along the shaft and down to the bottom of his penis with an open wound around the shaft and about 80% granulation tissue and 20% slough. He had no Pressure ulcer. CR #1 was still being treated with intravenous and oral antibiotics. The hospital nurse said they were treating the wound with wet to dry dressing changes. During an interview on [DATE] at 4:40 p.m., the Director of Nursing said that CR #1 was admitted into the facility with an indwelling catheter on [DATE]. When asked why his admission MDS assessment did not show documentation of the catheter, she said that she did not know. When asked about CR #1's wound assessment, the DON said his pressure ulcer was a stage 2 on his sacrum. She said that she did the resident's admission skin assessment in the presence of two other staff and that the wound was a stage 2 and it healed within three days. During an interview on [DATE] at 5:24 p.m. with CNA 57 in regards to CR #1 she was asked did she ever provide care for him and she answered, I don't remember, never took care of him. During an interview on [DATE] at 5:45 p.m., the DON said CR #1 was admitted from hospital with the catheter and that it was placed on [DATE] at the hospital. She also said the resident had the catheter placed due to [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder. During an interview on [DATE] at 10:13 a.m. with LVN CE, she said in regards to CR #1 he used to sing and everything while doing his care. His right arm was swollen when he came. She said she would help the Treatment Nurse turn him. She said he had a Foley catheter. She said she knew she had taken care of him through the week but could not remember the day. She said his hand was hurting and she gave him a [MEDICATION NAME] and breathing treatment. She said he was sitting up in a chair. She said she could remember that when you got him out of bed, all he wanted to do was go back to bed and he liked to talk. During an interview on [DATE] at 11:00 a.m., the Treatment Nurse (RN AB) said CR #1 had intermittent confusion, his bottom and scrotum were intact. He had a Foley catheter. During an interview on [DATE] at 11:43 a.m. with CNA 31, she said she remembered CR #1. She said she was out for about 6 weeks and returned on the 7th of August. She said CR #1 was a real nice gentleman. She said he started going to the dining room, was taking therapy, and she would give him his showers on Monday, Wednesday and Friday. She said there were no concerns for him. She said he had a little red area on his buttocks and she documented it on the shower sheet and in a couple of days the red area was gone. She said he was incontinent of both bowel and bladder, no Foley or ostomy, but could not really remember. During an interview on [DATE] at 11:51 a.m. with CNA 44, she said that CR #1 was nice, sweet, and that she helped him with everything, he asked, showers, and assist to chair. She said he was incontinent of bowel and bladder and had a urinary catheter. She said there were no problems or skin issues. During an interview on [DATE] at 12:00 p.m., the ADON when asked what she knew about CR #1, she said he was admitted during the middle of July, had an indwelling catheter, and [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. She said the resident was cognitively confused intermittently and complained of pain to the Right shoulder. When asked whether she had any discussion with CR #1's Physician or NP's recently she said not that she could .remember or think of. When asked whether she had discussed with the Nurse Practitioner (NP) with the therapy department she said that Nurse Practitioner (NP) on one occasion said to her in a joking manner something about the resident's catheter and that he, CR #1, said he was going to call an Attorney. She said she did not know what the complaint was about and that it took place about 3 weeks prior. She also said she asked the nurses if CR #1 had complained to them about his catheter and they said no. When asked whether he was being given showers she said she had seen staff take him for showers. A request was made to review the resident's shower sheets from admission to his discharge. When asked if the NP discussed with her the Resident's complaint of pain of his privates she said she never discussed anything about that with her. She also said the resident had never complained to her or the staff about pain to his private area or with the catheter. When asked if she assessed the resident's catheter when the NP notified her of resident's complaints about his catheter, she said that she looked at the drainage bag and tubing and it was clean and she did not check the catheter or his penis because he was sitting in his chair. She said if the NP had told her about pain in the resident's private area she would have assessed the area and would have notified the DON and resident's Physician. During a telephone interview on [DATE] at 12:06 p.m., CNA 16 said that she worked at the facility PRN (as needed) and that she had taken care of CR #1. She said that he had a Foley catheter and sores in his private area, looks like he has a cut down there. When asked if she notified her nurse, she said she did not notify the nurse because the sores and cut looked like they had been there for a long time. She said she would have thought the nurses should have known and that as a PRN staff she had not worked since the last few weeks. She said that while cleaning him she had to be careful because it hurt him. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 16 took care of him on [DATE], [DATE], [DATE], [DATE] and [DATE]. Resident was sent to the hospital on [DATE]. Additionally, record review of the Catheter Output Roster revealed that from [DATE] (admitted ) to [DATE] (discharge date ) staff were documenting that Catheter care was provided each day as follows: [DATE] - 1 time [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 4 times [DATE] - 2 times [DATE] - 1 time [DATE] - 5 times [DATE] - 2 times [DATE] - 3 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 3 times [DATE] - 2 times [DATE] - 4 times [DATE] - 3 times [DATE] - 3 times [DATE] - 1 time [DATE] - 5 times [DATE] - 3 times [DATE] - 2 times No documentation from any staff reporting of CR #1 having wound to his penis and sediments in his urine. Record review of CR #1's Catheter Output Roster from [DATE] through [DATE] revealed that CNA 57 signed indicating she provided care for CR #1 on the following days: [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE]. During an interview on [DATE] at 2:47 p.m. with CNA 57, she was asked about caring for CR #1 again and was shown his picture from his medical record and where she had documented care, including Foley catheter care. She said she recalled care provided saying she never took care of his catheter but could remember feeding him. When asked why did she sign that all care was provided on her on behalf, she replied, that she went around asking other CNA's about their residents things like output and care and entered the information in the kiosk for them in order to keep it from going into red. She said she would go ask the CNA's how much a resident ate and would go report to the nurse if there was a change in condition. She said no one ever told her about a problem with CR #1's catheter or penis but if they did, they were supposed to report it to the nurse. During an interview on [DATE] at 12:50 p.m., the DON she said CR #1 was admitted to the facility with an indwelling catheter but could not remember whether it was changed or not and that best practice should be to document date /time when catheter/bag/ tubing was changed. She also said she did not receive any report and did not hear that he was complaining of pain in his private area. The DON said the implications of not assessing a resident's catheter could be possible retention of urine, and swelling in his pubic area and penis. When asked if staff doing catheter or incontinent care would have seen it if the resident had swelling, sores, and cuts, she said yes, they should have noticed that but if they did not report it nobody would know. Record review of CR #1's shower sheet for [DATE] and [DATE] revealed no documentation of any abnormal finding or wound to the resident's penis. There were no shower sheets for the other days from [DATE] to [DATE]. During a telephone interview on [DATE] at 3:50 p.m. with Physician A, he said he did not receive any calls from the facility regarding sores/cuts or wound on CR #1's penis and he was not notified about his having sediment in his urine. During an interview on [DATE] at 11:55 a.m., the NP for the therapy department said CR #1 had complained to her a couple of times that he was having pain in his privates anytime he saw her and he explained to her that the pain could be from his catheter. The NP said she checked with the nurses and they said he did not complain to them about pain in his catheter or his private area. She also said she had a discussion with the ADON regarding the resident's complaint of pain to his privates and asked for her to look into it and follow up with his Physician. When asked what she would usually do if she had any issues or complaints from any resident, she said she would notify nursing and if the resident's Physician was available, she would mention it to them. She said it was not in her role to assess resident's privates/penis but to notify nursing and she was not sure if he had any problem with his privates or that it was emergent and did not convey it to the ADON as if it was emergent. When asked when she started seeing CR #1, she said from [DATE] to [DATE]. During an interview on [DATE] at 11:25 a.m., the DON when asked whether a staff should document care another person performed, she said that catheter care was done by CNA's and nurses performed care of Suprapubic catheters. She said that whoever did the care should document it and that a CNA should not document care performed by another CNA. Resident #15 Record review of Resident #15's Admission record revealed he was [AGE] years old and was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #15's Admission MDS assessment dated [DATE] revealed he was assessed as having a BIMS score of 11 indicating moderately impaired cognition. He was totally dependent on staff for transfers, dressing, eating, toilet use, personal hygiene, and bathing. He needed the extensive assistance of staff with bed mobility. Record review of Resident #15's plan of care dated [DATE] revealed a plan of care for being at risk for complications related to Cardiac Pace Maker in place, at risk for impaired cardiovascular functions, staff assistance for all ADL's, full code, difficulty recalling recent events and use of indwelling suprapubic catheter due to [MEDICAL CONDITION] bladder and at risk for developing Urinary Tract Infections. Record review of Resident #15's Nurses notes for [DATE] revealed documentation of vital signs/status of resident ( per nursing - time reflected was when nurses documented the vitals and not necessarily when the vitals were taken) as follows: --[DATE] at 6:25 a.m. - RN AA documented Resident #15's Temperature 100.5 degrees Fahrenheit, axillary. MD notified, STAT labs and Chest X-ray ordered. --[DATE] at 11:03 a.m. - LVN/Unit Manager (UM) documented that Chest X-ray result revealed left lower lobe increased opacity with consideration for pneumonia, atelectasis and pleural effusion. Notified attending Physician and awaiting response. --[DATE] at 11:21 a.m. - RN AD documented for vital signs taken at 9:00 a:m (per interview with RN AD on [DATE] at 12:20 p.m.): O2 Saturation (SAT) 82% on Room Air (RA), Respiration (Resp) 20, Pulse(P) 123 bpm; resident was put on Oxygen (O2) at 2 liters and Blood Pressure (BP) ,[DATE] mmHg; Physician/Responsible Party (RP) notified. --[DATE] at 11:30 a.m. - RN AD documented she noted the Suprapubic catheter was draining scant urine, MD notified with order to replace catheter, consent obtained from responsible party. --[DATE] at 1:17 p.m. - LVN M documented Resident was difficult to arouse upon verbal and tactile stimuli upon arrival of a visitor. Resp. (respirations) 14 bpm (breathes per minute) , BP (blood pressure) ,[DATE], P (pulse) 62 and no temp. (temperature) and no 02 SAT (oxygen saturation). --[DATE] at 1:32 p.m. - LVN M documented temp. 99 temporal, MD notified and ordered to send Resident #1 out to VA hospital. Contracted Ambulance Response notified at 1:00 p.m. --[DATE] at 2:15 p.m. - LVN M documented - Non rebreather mask applied to resident with O2 (Oxygen) at 15 liters, resident remains stable at this time, 911 arrived at 2:10 p.m., report given, resident still breathing. --[DATE] at 3:00 p.m. - LVN M documented - Addendum: Contracted transport ambulance refused to transport resident due to their assessment of resident which resulted in 911 being called. --[DATE] at 3:31 p.m. - LVN/UM documented a late entry for 2:20 p.m. - 911 in room performing Cardiopulmonary Resuscitation (CPR) on resident starting approximately 2:15 p.m. and [MEDICATION NAME] 15 minutes. Resident left via stretcher escorted by 911 staff. Family members at bedside, attending physician updated. During an interview with Physician #2 on [DATE] at 3:15 p.m. he said that initially he was called about Resident #15 and was told that the resident was not doing well and he ordered some blood work, urine test and chest x-ray. He said he received another call notifying him of the chest x-ray results and that they had not received the results of other blood work. The Physician initially said he believed the staff did what they were supposed to do. He said he talked to the staff at the hospital and they said the resident basically coded. He also said when he spoke with the Medical Examiner he told him he did not need an autopsy and that the body had been released to the funeral home. When asked to explain further, he said that Medical examiners look for wrong doing for an autopsy to be done. When asked if he left any parameters or guidelines as to when to be called he said no and that it was easier to just call him when they have any issues. When asked of the Physician if the facility notified him when Resident #15's O2 SAT dropped to 82% in the morning; when they could not get O2 SAT on him later that morning; when his BP dropped to ,[DATE] and when he became difficult to arouse upon verbal and tactile stimuli, he said he was not notified of those findings and did not know about the situation. When asked what he would have expected the facility to do in those situations, he said he would expect staff to call him immediately. During a confidential interview the person said that they were concerned about the amount of time it took for Resident #15 to receive medical attention including transporting the resident to the hospital. This person raised concerns about the facility in that they failed to call 911 earlier and felt that Resident #15 would still be alive if medical attention needed and transport by 911 were contacted. They said there was confusion during his time of need. He stayed at the facility for two hours instead of being transferred properly. During an interview on [DATE] at 1:45 p.m., LVN M said she was the desk nurse on the date of the incident, [DATE] and that as the desk nurse she was responsible for charting skin assessments, weekly notes, antibiotic charting, and getting paper work ready for resident appointments amongst other tasks. She said she knew what was happening when a visitor came to the desk and said she was Resident #15's visitor and his condition was not good and wanted to know what was happening. She also said RN AD was the floor nurse that had the resident. She further said she went to the room with RN AD to assess the resident and did vital signs on him as follows: BP ,[DATE], P 62, and Resp. ,[DATE] and could not get O2 reading. She said the resident did not respond to his name. She said RN AD left the room and came back and told her the resident was going to be sent out. At about 1:30 p.m. LVN M wrote the transfer order, and prepared transfer papers. She said she did not know what time the transportation was called but noted transport arrived about 1:50 p.m. She said that when transport arrived, they came to the desk and told her they could not transport Resident #15 because they did not have the proper equipment. She called the DON and she said to call 911. When 911 staff came most of the staff went to the room. She said she documented what she was asked to write by LVN/UM. When asked what she should do when a resident had a change in condition, she said assess the resident, obtain vital signs, call the MD, notify DON/RP, and follow MD orders. She said if a resident's condition became worse she would call 911 and notify the MD. LVN M was able to enumerate what to do when she got a new admission including assessment of skin and indwelling catheter - when it was inserted and how urine looks. She said she should get physician's orders [REDACTED]. During an interview on [DATE] at 3:30 p.m., LVN/UM said she was made aware by RN AD that Resident #15 had a temperature of 100.5 degrees Fahrenheit and she gave him Tylenol. She said they document vital signs on their nurse's notes and some on the Medication Administration Record [REDACTED]. She said she was on another hall when she learned about the resident's condition and on getting to the room [ROOM NUMBER] was already there doing CPR. She said the DON with other nurses were in the room. She said she knew the MD was notified of X-ray results but not when his O2 SAT dropped/vital signs. When asked what staff should do when a resident had a change in condition, said they should assess resident including getting vital signs and O2 SAT, call MD and RP and carry out MD orders. She also said others should be documented in the nurse's notes and on their SBAR. She said nurses should not administer medications/treatments without a physician's orders [REDACTED]. During an interview on [DATE] at 5:12 p.m., the DON when asked whether she knew Resident #15 had a change in condition and what happened, she said she knew he had a change in condition and was going to the hospital. She then said she received a call from the nurse that the transport company refused to transport Resident #15 because they could not get an O2 SAT reading on him. She said 911 was already called. She said when she got to the room the resident was still breathing, 911 staff came, checked and obtained his pulse, and then started bagging him and putting in an IV catheter. When the 911 staff came into the room, they intubated him and started CPR. She further said they worked on him for a while before taking him to the ER. When asked whether they should have called 911 instead of the ambulance transport service they use she said the staff had called the ambulance transport service because the resident was clinically stable. She also said when his O2 SAT dropped to 82% Oxygen was applied and he was always having high heart rate even on admission. She said she did not know staff could not get his O2 SAT at 1:17 p.m. as per the nurse's notes and did not know if vital signs were done between the hours of 11:21 a.m. and 1:17 p.m. She said there were many people in the room and thought vital signs were done during that time frame. Requested documentation of the vital signs/monitoring of the resident during the time frame, none was provided provided prior to exit on [DATE]. When the DON was asked if she conducted an investigation regarding the incident, she said yes and she felt anything that needed to be done was done. Surveyor requested for the investigation report. The DON left the room and returned about 10 minutes later and said she did not write the report unless the surveyor wanted her to go and write one then. During an interview on [DATE] at 10:00 a.m., the DON when asked who was responsible for making decisions as to whether to call 911 or call their contracted Ambulance service she said the Charge Nurse was the person to make the decision. If the condition worsened, the nurses could make the decisions and then notify her. She said she could update or change the decision if she was available. When asked if Resident #15's Physician had parameters or guidelines as to when staff(TRUNCATED)

Based on observation, interview and record review the facility failed to ensure 1 of 24 residents reviewed for supervision (Resident # 21) received adequate supervision to prevent injury and that the environment was free of hazards on 3 of 4 halls (100 hall, 200 hall and 400 hall). This was evidenced by: Resident #21 was hospitalized to remove foreign objects from his rectum and colon. The clean utility room by Station 2 on the 200 hall had left over trays that had eating utensils, table knives, forks, and spoons assessable to residents. One of one shower rooms on the 400 hall was un-locked. The shower room contained chemicals and wire clothes hangers. One of one Electrical room on the 400 hall was unsecured. One of four medication rooms on the 100 hall had broken or missing cabinet doors. These failures affected one resident and placed 128 residents and staff at risk of injury or being exposed to hazardous equipment and chemical. # 3 and # 7 Findings include: Review of the clinical chart for Resident # 21 revealed the [AGE] year-old resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED].{BPH} without obstruction of the lower urinary tract system, Atherosclerosis, Vascular dementia, Depressive Disorder, Joint Pain--Pelvis and Adjustment Disorder-Emotion/Conduct. Record review of Resident #21's quarterly Minimum Data Set assessment dated [DATE] revealed the Resident had short and long-term memory imapirment, moderately impaired daily decision making skills and required supervision. Resident #21 had psychosis without hallucinations or delusions. He needed extensive assistance of one person for bed mobility and assistance of two people for transfer. The Resident was assessed to need supervision only with mobility when up in his wheelchair. He did not have impairment of range of motion in either the upper or lower extremities. Record review of the interim care plan dated 9/17/14 developed following Resident #21's re-admission to the facility on [DATE] after his surgery read in part, Goal/Objective: "...will have measures to reduce possibility of resident inserting foreign objects inappropriately ..." The review revealed no information as to what measures were to be taken. There was no specific goal or time frame for the problem of " Altered skin integrity R/T Rectal Prolapse due to foreign object " . The only interventions were 1. Check room daily for objects. 2. Routine rounds daily to check room. 3. Provide a safe environment as possible. 4. Notify doctor promptly with any signs of rectal problems. Record review of Resident #21 ' s care plan with a revision date of 08/05/14 (before the Resident was discharged to the hospital for surgery) revealed that there was no care plan related to behaviors of placing foreign objects in his rectum. Observation on 09/17/14 at 2:00pm of Resident #21 revealed that he was in bed with his call light within reach. This was a regular call light within reach not a modified call light pad. Review of the clinical chart revealed a previous incident. physician progress notes [REDACTED]. had incident when he put the call light into his rectum..." Record review of Resident #21's "Preliminary Report" from the hospital dated 9/11/14 read, "...foreign body was seen at 12 cm in the rectosigmoid area, this foreign body... turned out to be a 6 X 1 and 1/2 inches plastic tube which had been inserted in the area". The review revealed the tube was removed. The document further read, "...A KUB was performed as well as a lateral film of the abdomen and this demonstrated foreign body apparently a spray bottle at the level of the ascending colon..." Further review revealed the spray bottle was removed via surgical intervention. Record review of Resident #21 ' s " Operative Report " dated 9/11/14 read in part ...A spray bottle, measuring approximately 8 x 2.5 inches was extracted very carefully from the colon ... Interview on 9/16/14 at 9:36am with CNA H revealed that all resident toothbrushes and toothbrsh covers were kept in plastic containers in the supply room, not in residents' rooms. Interview on 9/18/14 at 10:40 AM with the Administrator, who was responsible for reporting abuse and neglect, revealed she did not report the incident to the State Agency as she was not aware of it until the surveyor came to the facility to investigate the incident, (9/12/14). Interview on 9/18/14 at approximately 1:10 PM with the DON revealed the facility's administration did not feel the situation was reportable as he felt the incident was a result of the resident's self-gratification. 200 Hall Observation on initial tour on 09/16/14 at 9:15am revealed the door to clean utility room was open. Inside were two trays one dirty and one clean. The tray both trays had knives, forks, and spoon all unsecured. In an interview on 09/16/14 at 9:30am LVN D said " this should not be here, she took the two trays away and closed the door. 400 Hall Observation on 09/17/14 at 1:30pm revealed one of one shower room on 400 hall by the Nurses station was unlocked. One of one cabinet inside the shower room had the following- A bottle of body lotion, labeled for external use only. Keep out of reach of children. A bottle of solution labeled Peri wash. Combs, tooth brushes, hair brushes and assorted hangers. In an interview on 09/17/14 at 1:45PM RN B said the door was broken two days ago and maintenance was working on it. In an interview with the Maintenance supervisor on 09/17/14 at 2:00pm, he said the fire department broke the door about a month ago. He said the door would be replaced. When asked why the fire department had to break the door down there was not a reason given. In an interview with the facility administrator on 09/17/14 at 3:00pm, she said the fire department broke the door. She said the facility was in the process of replacing the door. She brought invoices for an estimate. When asked why the fire department had to break the door down there was not a reason given. Observation on 9/17/2014 at 1:35pm of 400 hall revealed the Electrical Room was unlocked. Inspection of the room revealed three electrical panels. No locking devices were evident preventing access to the interior panels. There was no staff members posted at the door while it remained unlocked. Interview on 9/17/2014 at 1:37pm with RN B revealed the door is supposed to be locked, and did not know why the door was not. Interview with the Administrator on 9/18/2014 at 12:10pm revealed there was no facility policy on access control. 100 Hall Observation in 100 Hall medication room, with LVN G, on 9/18/14 at 11:00 am revealed 2 doors of the cabinet below the sink were missing, and 1 of the doors was hanging loose off the hinges. In an interview with LVN G at the time, she stated that there was a work order for maintenance to replace the doors, and all the med rooms would be remodeled. In an interview with the Administrator on 9/18/14 at 2:00 pm, she stated she had work orders for the shower doors and med rooms repairs, and would supply a copy for surveyors. Facility 672 dated 09/16/14 listed a census of 134; 5 residents listed as Bedfast most of the time.

Based on observation, record review and interview the facility failed provide adequate supervision and assistance devices to prevent elopement and ensure safe transfers for eleven of twenty residents who wandered and needed safe transfers by staff, resulting in the elopement of one resident who required hospitalization after being found out of the facility approximately 14 hours later. The facility failed to: - supervise residents identified by staff as wanderers; Residents #15 removed wander guard 10/18/11, no interventions by staff then on 10/30/11 he eloped and was not located by staff.; Resident #18 identified as a wanderer on 01/25/11 was found wheeling herself down the street on 07/23/11; Resident #30 was identified as a wanderer and did not wear a Wander guard; Resident #31 had documented elopement attempts and removed her Wander guard in June 2011 and did not wear a Wander guard during survey until 11/17/11; Resident #32 was not appropriate for Wander guard device on 2 different elopement assessments, 12/2010 and 09/2011. The 10/31/11 Elopement assessment revealed she was appropriate for Wander guard having a history of elopement. Resident #33 - No Risk assessment in record; Wanderguard device placed 09/2010 and care planned 10/2011. - provide a safe environment, on 11/15/11 at 6:10 am cardboard was observed stuck in an exit door to keep it from locking. - maintain alarmed and other exit doors in working order, - ensure staff reported malfunctioning doors attached to wander guard system timely to prevent elopement and - provide safe transfers of residents who needed assistance with transfers Residents #35, #36, #37 and #38) On 10/18/11 Resident #15 removed his wander guard bracelet, then on 10/30/11 eloped from the facility. He was found on 10/31/11 at 8:45 am by local police and taken to a hospital by Emergency Medical Specialists (RMS). Resident #15 had [DIAGNOSES REDACTED]. These failures caused harm to Resident #15 and placed 19 current wandering residents/residents needing safe transfers at risk for harm and exposure to environmental, social and traffic hazards away from the security of the facility. Findings include: Resident #15 Record review of the closed medical record for Resident #15 revealed he was a [AGE] year old male admitted on [DATE] to the facility. Resident's [DIAGNOSES REDACTED]. Resident #15's responsible party had concerns of Resident leaving the facility. On 10/7/11 Resident #15 was assessed for a wander guard and a wander guard was placed on his left wrist. On 10/18/11 Resident #15 took off his wander guard and made attempts to exit the facility. On 10/18/11 the social worker informed the nursing staff about Resident #15's attempts to leave and that he had taken off his wander guard band. Record review of Resident #15's medical record and care plans dated 10/18/11 revealed no new interventions or assessments were done after Resident #15 attempted to elope on 10/18/11. On 10/30/11 Resident #15 took off his wander guard and successfully eloped from the facility during or after eveing meal at about 6 PM. Resident #15 was found by police on 10/31/11 at 8:45 AM and taken to the hospital(hospital #2) by ambulance. Record review of Resident #15's emergency medical services report dated 10/31/11 revealed the following: "History of Present Illness... Complaint, weakness and syncope." Resident #15 had admitting [DIAGNOSES REDACTED]. The Weather Channel reported an observed low temperature of 44 degrees Fahrenheit (F) on 10/30/11. Resident #15 sustained Rhabdomyolysis, syncope and dehydration due to over exertion and due to the outside environmental elements. Record review of Resident #15's local hospital #1 history and physical revealed that he was admitted to hospital #1 on 9/24/11 due to wandering around and out of control behavior and admitted to the facility on [DATE]. Record review of Resident #15 's progress notes by the facility's physician dated 10/10/11 revealed [DIAGNOSES REDACTED]. Record review of Resident #15's care plans dated 10/7/11 revealed "Problems/ needs Resident wanders into unsafe situations, Goal & Target date Resident safety will be met in a safe, environment, concerns will be identified and addressed thru next 90 days Approaches: Place Resident in area where frequent observation is possible, place monitoring device on Resident that sounds alarms when resident leaves building, alert staff to Resident's wandering behavior, provide diversional activities for Resident, approach Resident positively and in calm, accepting manner, If Resident is wandering away from unit instruct staff to stay with Resident, converse and gently persuade Resident to walk back to designated area with them, note which exits Resident favors for elopement from facility. Alert staff near those areas. " Review of Resident #15's Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #15 had both short and long-term memory problems and he missed or could not recall items on the interview assessment, he could not complete the assessment recall missed interview questions. Resident #15's Behavior section of the MDS revealed that he had wandering behavior daily. Record review of Resident #15's social services notes dated 10/18/11 revealed:" Resident observed making attempts to seek exiting the facility, expressed, I 'm looking for the bus ", easily redirected, easily redirected. Wanderguard put in place yet resident has successfully been able to remove. Staff to monitor resident ' s wherabouts. Due to confusion and dementia, resident has poor judgment and safety awareness. Will monitor for future safety risk and possible need for secured unit and contact family. Record review of the nursing notes dated 10/18/11 revealed: "The social(sic) called this writer that Resident#15 was trying to exit the door but social worker redirected him. Resident have no wander guard on him at this time. Resident took off the wander guard that was placed on him when he was admitted ... Resident is still on elopement precaution. Resident is in bed sleeping, no any other abnormal behavior noted during this shift. Will pass this information to 10-6 nurse to monitor resident until new wander guard is placed on him." Record review of the nurses notes from 10/18/11 to 10/28/11 revealed no documentation that a new wander guard had been placed on Resident #15 ' s wrist. Record review of Resident #15's nursing notes dated 10/28/11 revealed Resident is alert and oriented to person. Disoriented to place and time. Ambulates independently, wanders about facility exit seeking . Requires redirections frequently." Record review of Resident #15 ' s care plans revealed there was no updated care plan to address Resident #15 removing the wander guard and there was no updated care plans with new interventions to address his wandering behavior and possible placement in a secured unit after elopement attempt on 10/18/11. Record review of Resident #15's care plans dated 10/7/11 revealed that Resident #15's room location was on the 400 hall. Observation on 11/15/11 at 3:22 pm of the wander guard door on the 400 hall revealed that the electrical power was off on the wander guard monitor and the wander guard did not go off when the wander guard band was tested . In interview at this time the Administrator stated "O my God" when he noticed that the power was off. In an interview on 11/15/11 at 3:22 pm Employee TT stated that she did not know why the electrical power was off on the wander guard door. In an interview on 11/15/11 at 3:33 pm the DON stated that no one reported to her that the power was off on the wander guard door. In an interview on 11/15/11 at 4:26 pm Employee SG stated that he checked the facility doors once a week but he did not document when he checked the doors. In continued interview Employee SG stated that he knew that the electrical power was "not working on the wander guard door on the 400 hall since about 10:45 am this morning." In an interview on 11/15/11 at 3:24 pm the Corporate Nurse stated that staff have to sit at the doors and monitor the doors. Observation on 11/15/11 at 3:25 pm of the wanderguard band revealed that if was a light weight plastic red allergy band that was easily broken. In an interview on 11/15/11 at 3:31 pm the Corporate Nurse stated that she would get different bands for the wander guard. In an interview on 11/16/11 at 8:34 am Employee SG stated that all of the exit doors have an alarm with key pad or alarm with key pad and wander guard. In further interview Employee SG stated that the staff and security guard should have responded to the door alarms going off when Resident #15 eloped from the facility on Oct.30, 2011 even if Resident #15 did not have his wander guard on. In continued interview he stated that the exit door alarms are set at 5:30 pm and the alarms go off when someone exits the doors. In an interview on 11/16/11 at 8:43 am Employee SG stated that staff are taking out the trash when they put the card board between the alarmed exit doors to hold them open. Observation of Resident #15 on 11/16/11 at 3:53 pm revealed that was on a secured unit at a new nursing facility #2. Further observation at this time revealed that Resident #15 was sitting on the sofa and he started talking in a confused manner. Continued observation revealed that Resident #15 start walking around the secured unit and he was trying to exit the locked doors. In an interview on 11/16/11 at 3:57 pm Resident #15 stated in a confused manner that he could go home from the last nursing facility when he wanted. Resident #15 also stated that he did not know where he was going and the police could not man handle him. In an interview on 11/16/11 at 4:03 pm with the Secured Unit Charge Nurse at Facility #2 he stated Resident #15 is alert and oriented to name only, he has poor short term memory, and he knows his daughter and granddaughter. He also stated that Resident #15 came to the secured unit facility #2 on 11/2/11. In an interview on 11/17/11 at 1:18 p.m. the Director of Nurses stated that the Social Worker did not make her aware that Resident #15 took off his wander guard on Oct. 18, 2011 and that he needed possible placement in a secured unit. She also stated that she did not know why the staff did not update Resident #15's care plan on Oct. 18, 2011 when he tried to elope and took off his wander guard and why he was not reassesed. In an interview on 11/17/11 at 1:32 p.m the Social Worker stated that she sent the DON a text message informing her that Resident #15 took off his wander guard and was trying to exit the facility . She also stated that she followed up with the nurse about Resident #15's wander guard and the nurse informed her that the staff had put another wander guard on Resident #15. In an interview in on 11/18/11 at 4:35 pm the Service Tech stated that the wander guard system have two modes of bypass, one is a visitor and one is a staff bypass. When vistors go through the wander guard the door alarm would sound if the resident with the wander guard was close to it. In staff by pass mode, the wander guard door would not sound if residents with wander guards went close to door alarm with staff. In continued interview he stated that all the doors are now in visitor by pass mode. He also stated that the doors were in staff by pass due to a power failure. WANDER GUARD AND ELOPEMENTS Resident #31 Record review of face sheet revealed Resident #31 was a [AGE] year old female, a resident of the facility since 04/07/09. Record review of November 2011 medication Administration record revealed [DIAGNOSES REDACTED]. Record review of a 03/02/11 Psychiatric recertification order recorded [DIAGNOSES REDACTED]. Observation on 11/18/11 at 10:15 am revealed Resident #31 was ambulating with a walker, dressed in street clothes. She did not have a wanderguard monitoring device on walker, wrists or ankles. Observation on 11/19/11 at 12:50 pm revealed Resident #31 was sitting in a common area in her wheel chair. She was wearing a wnadreguard monitoring device on her left wrist. One of two snap closures was disconnected In an interview on 11/19/11 at 12:50 pm Resident #31 said, of her monitoring device, she just got it in the last day or two. In an interview on 11/19/11 at 12:55 pm LVN S said Resident #31 had always had a resident monitoring device. She did not know when the facility put the grey wrist band of the monitoring device on Resident. That one was new. She had never seen that one before. Record review revealed the following: ELOPMENT ATTEMPT: 06/17/10 Nurse's Notes (Error in recording year. This entry was between two 2011 nurses notes.) " 4:00 pm Resident #31 noted attempted to go out of doorway of facility. Resident stated she wanted her handbag from the car. Wanderguard to left hand. " ELOPMENT ATTEMPT: 06/22/11 Nurse's Notes: "4:20 pm Resident #31 attempted to go out of door. She was redirected to her room. Resident stated she took off the Wanderguard from her hand. She said it will not happen again. " 06/30/11 Psychiatric physician progress notes [REDACTED]. " 10/31/11 Risk of elopement review: "Potential risk factors ...Resident #31 is cognitively impaired with poor decision making skills ...Resident ambulates independently with or without the use of assistive devices ...Resident has a history of leaving facility without need of supervision and Resident has history of leaving facility without informing staff. (The number of elopement events was not recorded as required on the risk assessment). Resident is at risk for elopement ...Interventions - personal safety alarm devices ...Physician orders [REDACTED]. Record review of Resident #31 November Administration record revealed "Monitor Wanderguard every shift, start date 11/19/11". Resident #32 Record review of face sheet and administration record revealed Resident #32 was an [AGE] year old female admitted to facility on 03/03/9 with [DIAGNOSES REDACTED]. Obervation on 11/15/11 at7:25 am revealed she was awake, alert resident up in wheel chair. She wore a red band with wander guard on her ankle. Record review of 12/2010 and -9/2011 elopement assessments revealed Resident #32 was not appropriate for Wanderguard. She scored 6 out of 10. A score of 10 or higher warranted use of wanderguard on the assessment form. Record review of administration record, monitoring of wanderguard began on 10/15/11. Record review of 10/31/11 Elopement assessment revealed she was appropriate for Wanderguard, "having a history of elopement". Resident #33 Record review of the 07/02/10 Face sheet revealed Resident #33 was an [AGE] year old Spanish speaking resident of facility since 12/26/08. Record review of her 07/02/10 Face sheet revealed [DIAGNOSES REDACTED]. Observation on 11/17/11 at 3:00 pm revealed Resident was bright, alert and confused. She was dressed in street clothes and wearing a resident monitoring device on her right ankle. The device had a white band. Observation on 11/18/11 at 4:55 pm revealed a gallon size plastic bag full of unused red hospital allergy alert bands with adhesive strip. Record review of Resident #33's chart revealed no Elopement Risk assessment from admission 12/26/08 to 11/16/11. 08/2011 Administration Record: " May have Wanderguard for elopement risk. Check placement every shift, to start 09/22/10. " Elopement risk care planned on 10/31/11. In an interview on 11/18/11 at 4:55 pm, Employee TT said she tested the batteries on all wander guards every week and recorded the findings on the Wanderguard Log. The system was upgraded when she got there. The red bands were in the supply room when she started her job (Facility employee listing revealed Employee TT hire date of 01/14/09). She said she did not know the red bands were not the manufacturer's bands to be used with the wander guards. She said she did not know where they came from and she could not find a delivery receipt for them. She said she was asked on ??DATE?? by facility to special order bands from the closest source, to be delivered on 11/16/11. She said she received the grey bands from the Contractor on 11/17/11, when he came to inspect the Wanderguard system. Exit DOORs Observations, on 11/15/2011 at 6:10 am revealed the exterior entrance to resident care area on 100 hall was propped open with cardboard. The surveyor entered the facility through this door from the outside, walked down the hall to nurses station one, past three unidentified staff members. No alarm sounded. During an interview on 11/5/11 at 6:10 am, LVN Q stated, " That door is always shut. We always enter through the ambulance door, " (adjacent to Nurses station one). Observation on 11/5/11 at 6:12 am revealed the exterior entrance door on 100 hall was closed and the cardboard was not in place. Observation on 11/15/11 at 6:13 am revealed the surveyor opened the door from the inside of the building and an alarm sounded. The cardboard was observed lying on the ground outside of the 100 hall door. Employee SB came to silence the alarm. In an interview on 11/15/11 at 6:13 am, Employee SB stated, "You have to use a key to enter this door from the outside of the building, then use a code when you enter to silence the alarm. If a person doesn ' t have a key, we use the cardboard between the door frame and the lock to keep the door open and when you come in, you use the code to silence the alarm. I never do this, but some do. " Observation on 11/15/11 at 6:16 revealed the surveyor, in the presence of Employee SB, open Hall 100 door, pick up the cardboard lying outside, and insert the cardboard between the door lock and door frame. The surveyor stepped outside the building, opened Hall 100 door from outside the building, and an alarm sounded. Employee SB silenced the alarm with a code entered into the keypad. This door does not have a wandergard alarm system. In an interview on 11/15/11 at 2:53 pm, Director of Nurses (DON) stated, " All doors that have a keypad should not open unless you input the code. DON and the surveyor walked to an exterior door located between Hall 200 and Hall 300. The door had a keypad. The surveyor opened the door, which led outside, without using the keypad. This door does not have a wandergard alarm system. In an interview on 11/15/11 at 3:05 pm Administrator stated, " I ' ve seen cardboard in the door a thousand times. We ' ll call and have a wandergard alarm put on that door. " Observation on 11/15/11 at 3:20 pm revealed the exit door on 400 Hall did not have power on the alarm. This door opens to the outside. This door has a wandergard alarm. The alarm did not sound when the door was opened. Interview on 11/15/11 at 3:20 pm Administrator stated, " We ' ll get someone to man this door. " Interview on 11/15/11 at 3:23 Employee SG stated, " A guy came last week to do maintenance on a wire in that door. It was working until the Life Safety Code guy came today and we noticed it wasn ' t working. " The surveyor asked Employee SG what time he noticed the door wasn ' t working. Employee SG stated, " He and I came through here about 10:45 or 11:00 am. I didn ' t get a chance yet to tell the administrator or DON that the door isn ' t working. A resident could escape if the door doesn ' t work. " Interview on 11/15/11 at 4:26 Employee SG said he checks the doors once a week but " I don ' t keep a record of it. " Review of facility policies & procedure revealed "... Work place Violence prevention Program & Security Program. All employees, including managers and supervisors, are responsible for using safe work practices, for following all directives, policies and procedures, and for assisting in maintaining a safe and secure work environment. " WANDERGUARDS- Resident #18 Review of Resident #18 ' s face sheet dated 6/30/11 reflected Resident #18 was a [AGE] year old female admitted on [DATE] and readmitted on [DATE] ( additional admissions occurred on 4/22/10, 1/24/11, 3/2/11, 3/11/11, 4/13/11), with the following medical Diagnoses: [REDACTED]. Record review of Daily Skilled Nursing Notes dated 1/25/11 reflected Resident #18 was ambulating from one room to another, saying she wanted to go home and asking for the exit door. Resident #18 ' s daughter was notified by telephone and gave facility permission to put a wanderguard on Resident #18. Record review of Resident #18 ' s Restraint Consent form dated 1/25/11 reflected Resident #18 ' s daughter gave telephone consent for the use of a wanderguard on 1/25/11 at 7:30 pm. Record review of Resident #18 ' s Resident Elopement Assessment originally dated 1/25/11 and updated on 3/18/11, 6/17/11and 9/20/11 reflected Resident #18 had an elopement risk score of twelve (12). A score of ten (10) or higher is " at risk " . Section I of the Elopement Assessment dated 1/25/11 reflected Resident # 18 ' s daughter gave knowledge of Resident #18 leaving the residence /premises without supervision two times. Review of Nursing Summary dated 7/8/11, 7/16/11 and 7/22/11 reflected Resident #18 had a short term memory problem, her decision making ability was moderately impaired and displayed exit seeking behavior. Review of Resident #18 ' s Elopement assessment dated [DATE] reflected an elopement score of 9. Section I of the Elopement Assessment dated 7/23/11 reflected Resident # 18 ' s daughter gave knowledge of Resident #18 leaving the residence /premises without supervision one time on 7/18/11. Review of Nurses Note dated 7/23/11 reflected a visiting family member of another resident observed Resident # 18 wheeling herself outside facility. Staff went outside and found the Resident wheeling herself down the street away from the facility. Review of facility investigation follow-up dated 7/23/11 reflected the recommended intervention for Resident #18 was a ' secured braclet. ' Review of Resident #18 ' s physician's order [REDACTED]. Interview on 11/15/11 at 4:42 pm, LVN B stated, " We don ' t need a doctor ' s order for a wandergard. It ' s a nursing intervention. " Interview on 11/17/11 at 9:19 am ADON stated, " We don ' t need consents for wandergards. It ' s a nursing judgment. " Resident # 30 Review of Resident #30 ' s face sheet dated 7/5/11 reflected Resident #30 was an eighty-six year old male admitted [DATE] with medical [DIAGNOSES REDACTED]. Observation on 11/18/11 at 5:47 PM revealed Resident #30 was in his room. Licensed Vocational Nurse (LVN) X accompanied the surveyor into Resident #30's room. LVN X checked Resident #30's arms and legs. No wanderguard was on Resident #30 ' s body. Record review of Resident #30's admission MDS dated [DATE] reflected Resident #30 was identified for wandering (behavior of this type occurred daily and risk of getting into a dangerous place) Review of Resident #30's Resident Elopement assessment dated [DATE] and updated on 11/16/11 reflected Resident #30 had a score of ten(10). A score of ten or higher is " at risk " Review of Resident #30 ' s Consolidated Physicians orders dated November 2011 reflected the following order (originally dated 7/12/11): Apply wandergard to left ankle for safety. Review of Resident # 30 ' s undated Care Plan reflected Resident #30 required a wandergard and identified Resident #30 for being at risk for injury. A hand written note on this portion of the care plan reflected: wandergard to the left ankle. Observation on 11/19/11at 9:45 am Resident #30 had a wandergard on his left ankle. Interview at 9:48 am LVN A said when she arrived for her shift this morning at 6:00 am, she was told to perform a visual hourly check on Resident # 30 ' s physical location and an hourly visual check for his wandergard. LVN A stated, " I only work weekends and I was not told to check him every hour last weekend. " Interview on 11/19/11 at 10:00 am Assistant Administrator (ADON) said LVN X told the DON that Resident #30 did not have his wandergard on last night around dinner. ADON stated, " The last time we knew he had his wandergard on was yesterday (11/18/11) between 6:00am and 2:00pm. There is no nurse ' s note indicating he didn ' t have a wandergard in place. " On 11/18/11, the surveyor checked Resident #30 at 5:47 pm and he did not have the wandergard on. Review on 11/19/11 of Resident #30 nurses notes reflected no note for 11/18/11 at 5:47 pm indicating Resident #30 did not have his wandergard on. Interview on 11/19/11 at 9:48 am LVN A was asked if there should be a nurses note written on 11/18/11 reflecting Resident #30 was found without his wandergard on. LVN A stated, " There should be one, according to good nursing practice. " LVN A agreed there was no nurse's note. Interview on11/19/11 at 12:10 pm DON said she was not told by LVN X that Resident #30's wandergard was not on his body. When the surveyor asked DON how Resident #30 got his wandergard off, DON stated, " I have no idea. " TRANSFERS Interview on 11/19/11 at 1:38 PM, Employee NM said she provides training and skills check off ' s for transfers using lifts. She said Resident #36 is a one person transfer, using a sit to stand lift. She said the safety strap around the patient ' s torso should be tightened and the shin pad strap should make contact with the skin and be tight enough for two (2) fingers to go between the calf and the strap. A.(2) Review of Resident #35 ' s face sheet reflected Resident #35 was admitted [DATE] with the following Diagnoses: [REDACTED]. Observation on 11/18/11 at 4:45 PM revealed CNA F and CNA G transferred Resident #35 from the bed to the geri chair. CNA ' s F & G positioned a large sling with burgundy straps under Resident #35. The sling was attached to a mechanical lift and Resident #35 was transferred to a geri chair. In an interview on 11/18/11 at 4:48 PM CNA G explained the aide ' s know which sling to use by the color coded sticker on the resident ' s door. Resident # 35 ' s sticker was beige (size small sling) and indicated T2( total two person transfer). CNA G said they use the color of banding on the sling that matches the sticker. CNA G stated, " The sling size to use for each patient is also in a book at the nurse ' s station. " CNA F and G agreed they had transferred Resident #35 using the wrong size sling and " it ' s unsafe to use the wrong size. " In an interview on 11/18/11 at 4:55 PM, CNA F and CNA G said they had been trained and in-serviced on the use of the mechanical lift. Review of Resident #35 ' s Lift/Transfer Assessment Form dated 9/30/11 reflected Resident #35 required a total mechanical lift. A size small sling was to be used. Review of Resident #35 ' s Activities of Daily Living Assistance and Support Log dated November 2011 reflected Resident #35 was totally dependent on staff for transfers. In an interview on 11/19/11 at 1:38 PM, Employee NM said she provides training and skills check off ' s for transfers using lifts. She said she provides in-services on slings, sizes of the slings and the reason the size of the sling is important. " I ' ve taught them that the wrong size sling is unsafe. " She said Resident #35 is a two person total mechanical lift using a small sling with beige banding around the sling. In an interview on 11/18/11 at 5:10 PM, Director of Nurses (DON) stated, " The tag on the door indicates the size of the sling and the CNA should verify the size of the sling they use to lift the residents. " Resident #37 Record review of face sheet revealed Resident #37 was an [AGE] year old male admitted to the facility on [DATE]. Record review of the 03/16/11 admission Face Sheet revealed he had [DIAGNOSES REDACTED]. He also had a pacemaker. Record review of 09/10/11 quarterly MDS revealed Resident #37 functional status, transfer requires extensive assistance, TWO+ persons physical assist. Record review of RS Resident #37 ' s Care Plan revealed - " Resident requires extensive assistance from staff for mobility and for activities of daily living. " Initiated on 12/11/08 with target dates of 03/30/09 and 12/30/11. Interventions included " Use sit to stand lift until resident is able to bear weight and pivot to wheelchair. Physical Therapy to provide strengthening exercise and training in ambulation. " Initiated on 12/11/08, with target dates of 03/30/09 and 12/30/11. " Resident is at risk for falls due to impaired mobility and due to poor safety awareness. History of frequent falls at home. " Care plans did not have any documentation of review by appropriate staff. Resident's name tag outside his room had a sticker indicating " SS " (Sit to Stand) transfer. In an interview on 11/15/11 at 4:30 pm LVN O said the bed alarm was new that day for Resident #37. He fell on [DATE]. When she saw the bed alarm attached to Resident ' s blanket, she said it should not be attached to the blanket but should be attached to the resident. Observation on 11/15/11 at 4:30 pm revealed Resident #37 was sleeping in his bed unarousable by LVN O. Both full length side rails were up and a bed alarm was pinned to his blanket. LVN O removed bed alarm and attached it to his hospital gown. Observation on 11/18/11 at 5:45 pm revealed CNA I transferred Resident #37 from a wheel chair to his bed using a sit to stand lift alone. CNA I utilized a hoyer lift sling with groin straps. (Sit to stand lift harness does not have groin straps) Resident ' s hands were placed on lift grips, but he removed them and CNA redirected him to hold on. Resident not able to coordinate feet placement or stand without physical assistance from CNA. He was not weight-bearing, stood at about 140 degrees, leaving his weight on the lift harness. His movements were tremulous. Observation on 11/19/11 at 7:30 am CNA K transferred Resident #37 from shower chair to wheel chair using a Sit to Stand lift and harness alone. Record review of RS Resident #37 ' s chart revealed there was no decision tree assessment in his record determining which type of lift could be used for his transfers. Note RS Resident #37 ' s name was written and crossed out on the top of RS Resident #38 ' s Tender Lift and Care Lift/Transfer Assessment Form (Functional Ability). Resident #38 Record review of face sheet revealed Resident #38 is a 61 y/o male resident admitted to the facility on [DATE]. Face sheet, 10/20/09, revealed [DIAGNOSES REDACTED]. Observation on 11/18/11 at 7:45 pm reve