Every finding on record at Arbor Grace Guest Care Center

Based on interview and record review, the facility failed to ensure that residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; and the resident's drug regimen was free from unnecessary psychotropic drugs and PRN orders for psychotropic drugs were limited to 14 days for 6 of 12 residents reviewed for unnecessary psychotropic drugs (Resident #3, Resident #5, Resident #53, Resident #10, Resident #25, and Resident #64). 1. The facility failed to ensure a rationale was documented in Resident #3's medical record for extending the PRN lorazepam 0.5mg (a prescription medication used to treat anxiety disorders: feelings of fear, dread, and uneasiness) order duration beyond 14 days. 2. The facility failed to ensure a GDR was attempted for Resident #5's buspirone medication (a medication used to treat anxiety) in February 2026. The doctor did not provide an appropriate rationale for not attempting the GDR. 3. The facility failed to ensure a GDR was attempted for Resident #5's Ambien medication (a medication used for insomnia) in March 2026. The doctor did not provide an appropriate rationale for not attempting the GDR. 4. The facility failed to ensure a GDR was attempted for Resident #53's Seroquel medication (a prescription atypical antipsychotic medication primarily used to treat schizophrenia, bipolar disorder, and major depressive disorder) in May 2026. The doctor did not provide an appropriate rationale for not attempting the GDR. 5. The facility failed to place a 14-day end date to Resident #25's psychotropic medication prescribed as needed for Lorazepam Oral Concentrate 2 milligrams/milliliter. 6.The facility failed to ensure a rationale was documented for Resident #10's Seroquel and no signature or date indicating response on recommendations for unapproved diagnosis of agitation. The doctor did not provide an appropriate rationale for not attempting a GDR. 7. The facility failed to ensure Resident #64's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or documented a rationale for the continued provision of the medication and heavy psychotropic and anticholinergic medication burden with potential major drug interaction. These failures could put residents at risk of psychotropic medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications. Findings included: 1. Record review of Resident #3's face sheet, dated 06/15/26, reflected that he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included chronic obstructive pulmonary disease (a progressive, incurable lung disease that blocks airflow and makes breathing difficult). Record review of Resident #3's significant change MDS assessment, dated 05/08/26, reflected that he had a BIMS score of 09, which indicated moderate cognitive impairment. He was able to make himself understood, and he was able to understand others. Record review of Resident #3's order summary report, dated 06/15/26, reflected this order: *Ativan oral tablet 0.5mg (lorazepam), give 1 tablet by mouth every 6 hours as needed for anxiety for 30 days. The start date was 06/08/26. The end date was 07/08/26. Record review of Resident #3's medication administration record for the month of June 2026 reflected that Resident #3 was not administered the lorazepam medication during the month of June 2026 as of June 17, 2026. 2. Record review of Resident #5's face sheet, dated 06/15/26, reflected that she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included paranoid schizophrenia (a subtype of schizophrenia marked by intense paranoia, hallucinations, and delusions), major depressive disorder (a serious mental health condition characterized by persistent, pervasive feelings of sadness, hopelessness, and a loss of interest in activities), anxiety disorder (mental health conditions characterized by excessive, persistent, and disproportionate fear or worry about everyday situations), and post-traumatic stress disorder (a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening, or deeply traumatic event). Record review of Resident #5's quarterly MDS assessment, dated 05/22/26, reflected that she had a BIMS score of 10, which indicated moderate cognitive impairment. She was able to make herself understood and she was able to understand others. Record review of Resident #5's order summary report, dated 06/15/26, reflected the following orders: *Ambien oral tablet 5mg, give 5 mg by mouth at bedtime for insomnia. The start date was 10/14/25. *Buspirone HCL oral tablet 7.5mg, give 1 tablet by mouth two times a day for anxiety. The start date was 10/14/25. Record review of Resident #5's Consultant Pharmacist/Physician Communication, dated 02/17/26, reflected: .Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for a trial dose reduction. Current order: Buspirone 7.5mg BID Recommendation: Buspirone 5mg BID. .This recommendation is to ensure lowest effective dose is utilized. If resident failed previous dose reduction attempt or is clinically contraindicated, please document clinical rationale below. The Physician/Prescriber response section was marked disagree, and no rationale was provided. The communication was signed and dated by the Physician on 02/21/26. Record review of Resident #5's Consultant Pharmacist/Physician Communication, dated 03/16/26, reflected: .Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for a trial dose reduction. Current order: Ambien 5mg QHS Recommendation: Ambien 2.5mg QHS. .This recommendation is to ensure lowest effective dose is utilized. If resident failed previous dose reduction attempt or is clinically contraindicated, please document clinical rationale below. The Physician/Prescriber response section was marked disagree, and no rationale was provided. The communication was signed and dated by the Physician on 03/21/26. 3. Record review of Resident #53's face sheet, dated 06/18/26, reflected that she was a [AGE] year-old female, most recently readmitted to the facility on [DATE], and initially admitted on [DATE]. Her diagnoses included schizoaffective disorder (a chronic mental health condition that combines symptoms of schizophrenia with a mood disorder). Record review of Resident #53's annual MDS assessment, reflected that she had a BIMS score of 07, which indicated severe cognitive impairment. She was usually understood and she was usually able to understand others. Record review of Resident #53's Order Summary Report, dated 06/15/26, reflected the following orders: *Seroquel oral tablet, give 100mg by mouth one time a day for schizoaffective disorder. The start date was 12/24/25. *Seroquel oral tablet 400mg, give 1 tablet by mouth at bedtime for schizoaffective disorder. The start date was 10/14/25. Record review of Resident #53's Consultant Pharmacist/Physician Communication, dated 05/08/26, reflected: .Resident is receiving the following psychoactive medications that are due for review. Per CMS regulations, please evaluate resident for a trial dose reduction. Current order: Seroquel 100mg QAM and 400mg QPM Recommendation: Seroquel 100mg QAM and 300mg QPM . .This recommendation is to ensure lowest effective dose is utilized. If resident failed previous dose reduction attempt or is clinically contraindicated, please document clinical rationale below. The Physician/Prescriber response section was marked disagree, and the rationale provided was To to continue Resident Stable [sic]. The communication was signed and dated by the Physician on 05/16/26. 4. Record review of Resident #25's face sheet dated 08/31/24, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #25's diagnoses included Chronic Obtrusive Pulmonary Disease (a progressive, incurable lung disease that causes restricted airflow and breathing difficulties), Chronic Pain, and Atherosclerosis of Coronary Artery Bypass Graft (the buildup of plaque within the surgically implanted vessels). Record review of Resident #25's quarterly MDS assessment dated [DATE], indicated Resident #25 sometimes understood others and had unclear speech. The MDS indicated Resident #25 had a BIMS score of 00 which indicated her cognition was severely impaired. MDS indicated that Resident #25 was taking an anti-anxiety medication. Record review of Resident #25's comprehensive care plan dated 05/04/26 indicated a problem initiation date of 8/21/24 revealed that, I have episodes of anxiety and at risk for fluctuation in moods. I refuse to let the facility staff shower me. I only allow my Family Member, who comes 3x per week and she will shower me. Record review of Resident #25's physician order revealed Lorazepam Oral Concentrate 2 milligrams/milliliter give by mouth every 12 hours as needed for anxiety/restlessness. Order started on 5/13/26 and had an end date of 11/13/26. During an interview on 6/17/26 at 2:34 p.m. the Director of Nurses said that residents who received psychotropic medications should have a 14-day end date for all as needed psychotropic medications. She said that it was the responsibility of nurses to ensure that appropriate end dates are set for as needed medications. During an interview on 6/17/26 at 2:43 p.m. the Administrator said that residents prescribed psychotropic medications should have a 14-day end date for their orders if it is ordered as needed. She said that residents with psychotropic medications should be managed by nursing staff. 5. Record review of Resident #10's Face sheet dated 6/17/2026 indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #10 had diagnoses which included Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills), Type II Diabetes ( a chronic condition where the body cannot use insulin properly, leading to high blood sugar levels that can damage organs), muscle weakness (a reduction in the strength of one or more muscles, which can result from temporary fatigue, lifestyle factors, or underlying medical condition), unspecified psychosis (term used to describe the presence of psychotic symptoms that do not align with a specific diagnosis) and hypertension (a common condition where the force of blood against the artery walls is consistently too high). Record review of Resident #10's admission MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others. Resident #10 had a BIMS score of 3 indicating she was severely cognitively impaired. Resident #10 required moderate assistance on toileting, bathing, and dressing upper and lower body. The MDS care area indicated Resident #10 was on psychotropic medication triggering a care area. Record review of Resident #10's Care plan, initiated on 5/5/2026 indicated Resident #10 had a diagnosis of Dementia/Alzheimer's disease and required a secure unit due to confusion, wandering, and risk for elopement. Resident #10's care plan also indicated she had potential for hallucinations, delusions, and behaviors related to Alzheimer's disease and received an antipsychotic medication. Interventions included administration of medications as ordered and monitor effectiveness and notify MD if indicated, do not confront, argue against resident's thoughts, ensure resident preferences are honored, maintain calm environment, and pharmacy consultation review quarterly and as needed. Record review of a physician order, dated 6/16/2026, indicated Resident #10 was ordered to have Seroquel 50 mg at bedtime for agitation and Zyprexa 5 mg twice daily for mood disorder. The physician order summary also included monitoring for observed behaviors such as hallucinations and delusions. The physician order summary included monitoring for side effects such as dry mouth, constipation, blurry vision, disorientation/confusion, difficulty urinating, hypotension, dark urine, nausea and vomiting, lethargy, drooling, EPS (Extrapyramidal) symptoms such as tremors, gait issues, agitation, restlessness, involuntary movement of mouth and tongue. Record review of Resident #10's MAR dated 5/1/2026-5/31/2026, indicated Resident #10 was prescribed Seroquel 50 mg 1 tablet at bedtime for agitation. Resident #10 was also prescribed Olanzapine 2.5 mg twice daily for psychosis starting on 4/30/2026. Resident #10's dose was discontinued on 5/22/2026. Resident #10 was restarted on Olanzapine 5 mg twice daily on 5/29/2026 for mood disorder and discontinued on 6/17/2026. During an interview on 6/17/2026 1:27 PM, ADON E said Alzheimer's was not the appropriate diagnosis for Seroquel. ADON E said appropriate diagnoses for psychotropic medications were Schizophrenia and behaviors that she could not recall. ADON E said Resident #10 did not have behaviors currently and did not know if Resident #10 had behaviors when she was admitted . ADON E said it should be documented if she was having behaviors. ADON E said Hospice was the one who put the diagnosis in for psychosis. ADON E said Hospice was the one who prescribed Seroquel on 3/30/2026 after Resident #10 was admitted on [DATE]. ADON E said Hospice was signing Resident #10's orders. ADON E said the resident could have a drug interaction with Seroquel and Zyprexa being the same drug. ADON E said it could cause an increase in falls and drowsiness. ADON E said the DON was responsible for the pharmacy consultant's recommendations and Physician communication. During an interview on 6/17/2026 at 2:32 PM, the DON said Resident #10 was not sedated. The DON said Resident #10 was engaged in activities. The DON said she did not think Resident #10 was on too many antipsychotic medications. The DON said Alzheimer's was not an appropriate diagnosis for Seroquel. The DON said Resident #10 was diagnosed with psychosis for Zyprexa and was an appropriate diagnosis. The DON said Zyprexa was discontinued today and Resident #10 was no longer on Zyprexa. The DON said she was responsible for following up on the recommendations for GDRs. The DON did not elaborate on a negative impact on the residents. During an interview on 6/17/2026 at 2:53 PM, the ADM said the nursing (DON or designee) was responsible for reviewing and recommendations and rationale for the use of psychotropic medications. The ADM said a resident could be negatively impacted depending on the resident medical conditions. 6. Record review of Resident #64's Face sheet dated 6/17/2026 indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #64 had diagnoses which included Senile Degeneration of brain (progressive decline in cognitive function, impacting memory), Type II Diabetes ( a chronic condition where the body cannot use insulin properly, leading to high blood sugar levels that can damage organs), chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), dementia (a syndrome characterized by a decline in cognitive functioning, affecting memory, thinking, behavior and ability to perform everyday task), depression (a common and serious mood disorder characterized by persistent feelings of sadness, loss of interest and a range of emotional and physical problems), and hypertension (a common condition where the force of blood against the artery walls is consistently too high). Record review of Resident #64's admission MDS dated [DATE] indicated she was usually able to make herself understood and usually understood others. Resident #64 had a BIMS score of 3 indicating she was severely cognitively impaired. Resident #64 required moderate assistance on toileting and bathing and required substantial assistance dressing upper and lower body. The MDS care area indicated Resident #64 was on psychotropic medication. Record review of Resident #64's Care plan, revised on 4/22/2026 indicated Resident #64 had a diagnosis of Dementia/Alzheimer's disease and required a secure unit due to confusion, wandering, and risk for elopement. Interventions included a staff member who will be present on the unit 24/7, baby dolls provided comfort and aromatherapy for relaxation and engage and have supervised activities. The Care plan also included Resident #64 had episodes of anxiety and was at risk for fluctuating moods. Interventions included administer medications as ordered, listen to resident concerns, monitor and document signs and symptoms of adverse effects as well as positive effects of medications, monitor and document signs and symptoms of adverse effects of medications given related to the underlying health problem, monitor and record any abnormal behavior or moods and monitor and report any mental status changes that occur with resident. Record review of a physician order, dated 6/17/2026, indicated Resident #64 was prescribed Lorazepam 0.5 mg 1 tablet every 4 hours as needed for anxiety indefinite per Hospice starting on 5/2/2026. Record review of MAR dated 5/1/2026-5/1/2026, indicated Resident #64 had an order for Lorazepam 0.5 mg 1 tablet every 4 hours as needed for anxiety indefinite per Hospice. Resident #64 was administered Lorazepam 0.5 mg on 5/17/2026. During record review of Pharmacy recommendations dated 4/15/2026 indicated Resident #64 had high-severity inappropriate drug therapy related to heavy psychotropic and anticholinergic medication burden with potential major drug interaction related to prescribed medication doxepin 10 mg BID, meclizine PRN, promethazine PRN, zaleplon, lorazepam PRN and methocarbamol with potential major drug interactions, including serotonin syndrome (excessive serotonin which the body naturally produces builds up in the body) risk with venlafaxine, tramadol, buspirone, mirtazapine, and additive respiratory/CNS (Central Nervous System) depression (a condition in which the brain and spinal cord reduce activity, leading to slower communication between nerves and impaired control over bodily functions) with prescribed medications (morphine PRN, lorazepam, zaleplon) indicating overall regimen likely contributing to falls and functional decline while increasing risk of adverse events in a frail, hospice patient where comfort is priority. The Pharmacy recommendations indicated an immediate review of hospice physician, nursing and family align medications with comfort-focused goals and reduce fall risk. Recommendations also included monitoring watching for sedation, falls, serotonin syndrome signs and hyponatremia (low sodium in the body) and reassess after changes were implemented. The Physician disagreed and signed on 5/20/2026. During an interview on 6/17/2026 at 12:40 PM, ADON E said she would review if there was a reason for Lorazepam to be ordered as needed by Hospice. The ADON E said Lorazepam should not be prescribed indefinite and said it should be for 14 days for anxiety medication. ADON E said the Physician did not want to change the medication regimen. ADON E said Hospice was responsible for the heavy burden of psychotic medication and anticholinergic medication. ADON E said it could cause the residents to be heavily sedated, side effects with all the different medications. ADON E said the facility had not had a meeting with the Hospice care team regarding the medications. ADON E said the first meeting was scheduled for July 15th. ADON said the DON was the one who handled the Consultant and Physician communication. During an interview on 6/17/2026 at 12:52 PM, the Social Worker said she schedules a care plan meeting after a couple of weeks of admission. The Social Worker said Hospice was invited to the care plan meetings. The Social Worker said she had an initial care plan meeting for Resident #64 on 4/15/2026. The DON would be responsible for reaching out to the Hospice company regarding the Pharmacy Communication about the high burden. The Social Worker said the high burden of psychotropic medications and anticholinergic could negatively impact a resident if a resident was taking too much medication and could cause a resident to be overmedicated. During an interview on 6/17/2026 at 2:32 PM, DON said the order for Lorazepam should not be written as prn indefinite for Resident #64. The DON said the nurse was responsible for ensuring the medication was not written indefinite for a PRN Lorazepam. The DON said the Physician disagreed with the recommendations for Resident #64 and signed disagreed. The DON said she did not go over the recommendation with the Physician. The DON said that was the end of the encounter if the Physician signs off on the fact he disagrees. The DON said she had talked to the Physician about it before, but it was difficult to get him to articulate the rationale. The DON said the Pharmacist and DON were responsible for ensuring the recommendations were followed up on. During an interview on 6/17/2026 at 2:53 PM, the ADM said Resident #64 was a Hospice resident, and she supposed the Hospice provider wrote the PRN order for Lorazepam. The ADM said the PRN medication should have an end date. The ADM said the nursing team was responsible for ensuring the medication was reviewed every 14 days. The ADM said a resident could have a change in condition, and she did not know what kind of changes. The ADM said it depended on the residents and overall medical conditions. The ADM said the DON or designee was responsible for reviewing recommendations and rationale for the use. She said it could negatively impact a resident depending on the resident's medical condition. During an interview on 06/17/26 at 11:22 AM, ADON E said they did not have a rationale for Resident #3's PRN lorazepam duration. She said they should have a documented rationale for the duration of his PRN lorazepam. She said the risk was that he could be overly sedated with lorazepam and have an unnecessary medication. She said the GDR recommendations the physician disagreed with for Residents #5 and Resident #53 should have had a rationale documented for why the GDR was clinically contraindicated. She said the risk was overmedication of residents. She said it put them at risk of unnecessary medications. She said a doctor giving a rationale of patient stable does not mean a GDR was clinically contraindicated. She said they did not question the doctor on his GDR rationale. During an interview on 06/17/26 at 02:11 PM, the DON said she felt that resident stable was not a good rationale for not attempting a GDR. She said there should have been a rationale given for why the GDRs were clinically contraindicated. She said the risk was unnecessary medications. She said Resident #3 should have had a rationale for the duration of the PRN lorazepam. She said the risk was unnecessary medications. During an interview on 06/17/26 at 02:25 PM, the Administrator said a rationale should be provided for why a GDR was clinically contraindicated. She said she felt resident stable was an appropriate rationale for why the GDR was clinically contraindicated. She said the risk was that they would not be aware of the outcome in change of medication and how it could be beneficial to the resident. She said there should have been a rationale documented for why the order for Resident #3's PRN lorazepam had a duration of 30 days. She said it was important so they could follow the order for what best benefits the resident. She said the risk was having an unnecessary medication. Record review of the facility's policy, Psychotropic Medication Use, last revised February 2025, reflected: .PRN Medication. .3. PRN orders for psychotropic medications are limited to 14 days. a. For psychotropic medications that are NOT antipsychotics: IF the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, they will document the rationale for extending the use and include the duration for the PRN order. .Gradual Dose Reduction 1. Residents on psychotropic medication receive gradual dose reductions (coupled with non-pharmacological interventions), unless clinically contraindicated, to determine whether the continued use of the medication is benefitting the resident, to find an optimal dose, or in an effort to discontinue the medication.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure the flour container in the dry storage room was in good repair and did not have a hole in it. 2. The facility failed to ensure the fryer was clean and free of grease buildup and food particles. 3. The facility failed to ensure the ice machine did not have a pink substance on the inside of the machine above the ice. These failures could place residents at risk of foodborne illness and food contamination.Findings included: During an observation on 06/15/26 at 09:08 AM, an initial tour of the kitchen was conducted. The following items were observed:1) inside the dry storage room, a container of flour was broken. There was a hole in the side approximately the size of a golf ball and the container was cracked. There was flour inside the container. 2) The fryer was covered with aluminum foil. When uncovered, there were food crumbs all over the fryer. The baskets had grease buildup, and the back of the fryer had grease buildup. 3) The ice machine had a pink colored substance on the inside at the top, directly above the ice. During an interview on 06/17/26 at 08:36 AM, the Dietary Manager said the ice machine should have been cleaned and not have any pink residue. She said the fryer should not have had food particles on it. She said the flour container should not have had a hole in it. She said they used the fryer on Sunday night, and she did not expect the evening shift to clean it after use. She said someone should have noticed the pink residue in the ice machine. She said the risk to the residents was possible foodborne illness or contamination. She said someone should have replaced the flour container. During an interview on 06/17/26 at 02:25 PM, the Administrator said there should not have been a pink substance in the ice maker. She said there should not have been food particles on the fryer or grease buildup. She said there should not have been a hole in the flour container. She said the risk was possible foodborne illness. Record review of the facility's policy, Sanitizing Equipment In-Place, dated 10/01/18, reflected: .Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for cleaning equipment in place in order to ensure that all equipment is thoroughly cleaned and sanitized to minimize the risk of food hazards.Procedure:1. Unplug electrically powered equipment, such as meat slicers and toasters.2. Remove any fallen food particles and scraps.3. Wash, rinse and sanitize removable parts using the manual immersion method.4. Wash the remaining food-contact surfaces, and rinse with clean water. Wipe down with a chemical sanitizing solution mixed according to the manufacturer's directions.5. Wipe down all nonfood contact-surfaces and rinse with clean water. Wipe down with a chemical sanitizing solution mixed according to the manufacturer's directions.6. Re-sanitize the external food-contact surfaces of the parts that were handled during reassembling. Record review of the Facility's policy, Ice Machines, dated 10/01/18, reflected: Policy: The facility will maintain the ice machine, scoop and storage container in a sanitary manner to minimize the risk of food hazards. The ice machine will be cleaned once per month or more often as needed. The scoop and storage container will be cleaned once each day. Record review of the Facility's policy, Ingredient Bins, last revised 06/01/19, reflected:Policy: The facility will maintain the ingredient bins in a sanitary manner to minimize the risk of food hazards. The ingredient bins will be cleaned each time the bin contents are replaced, or more often as needed.

Based on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 2 residents reviewed for misappropriation of resident property. (Resident #4) The facility failed to prevent CNA J from stealing Resident #4's debit card and withdrawing $1600 dollars from her account. These failures could place residents at risk for decreased quality of life, misappropriation of property, and dignity.Findings included: Record review of Resident #4's face sheet dated [DATE] indicated Resident #4 was a [AGE] year-old female who was readmitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), Type II Diabetes (a chronic condition where the body cannot use insulin properly, leading to high blood sugar levels that can damage organs), severe protein-calorie malnutrition (an imbalance between the nutrients the body needs and the nutrients it gets), dementia (a syndrome characterized by a decline in cognitive functioning, affecting memory, thinking, behavior and ability to perform everyday task), cognitive communication disorder (a condition in which impaired cognitive processes disrupt a person's ability to communicate effectively) and hypertension (a common condition where the force of blood against the artery walls is consistently too high). Record review of Resident #4's quarterly MDS assessment dated [DATE] indicated Resident #4 was usually understood and understood others. The MDS indicated a BIMS score of 7 which indicated severe cognitive impairment. The MDS also indicated Resident #4 had inattention and was easily distracted. The MDS indicated Resident #4 required moderate assistance with bathing, dressing upper body and required substantial assistance with dressing lower body. Record review of Resident #4's care plan revised on [DATE] indicated Resident #4 had paranoid and suspicious behavior related to cognitive impairment. The Care plan indicated Resident #4 would report things stolen but would locate items in room. The care plan indicated Resident #4 kept her debit card with her and would not allow staff to keep it in a safe and often reported it stolen. Interventions included not to invade Resident #4's personal space, establish daily routine and explain procedures such as what, when and for how long and explain why you are entering room and going into closet and cupboards. Record review of hospital records dated [DATE], indicated Resident #4 was hospitalized for acute cystitis with hematuria (a bladder inflammation, often due to bacterial infection, that causes blood in the urine) from [DATE]-[DATE]. Record review of transaction summary dated [DATE], indicated Resident #4 had the following withdrawals from her debit card and withdrawal fees:[DATE] ATM withdrawal of $202XXX[DATE] ATM withdrawal of $202XXX[DATE] Card purchase from convenient store $40XXX[DATE] ATM withdrawal fee $0.85XXX[DATE] ATM Withdrawal $202XXX[DATE] ATM withdrawal fee $0XXX[DATE] ATM withdrawal $202XXX[DATE] ATM withdrawal $ 203XXX[DATE] ATM withdrawal fee $0.85XXX[DATE] ATM withdrawal $200XXX[DATE] ATM withdrawal fee $0.85XXX[DATE] ATM withdrawal $200XXX[DATE] ATM withdrawal fee $0.85XXX[DATE] ATM withdrawal $200XXX[DATE] ATM withdrawal fee $0.85. Record review of a Provider Investigation Report dated [DATE] indicated the ADM requested the Social Worker to obtain resident's bank card code number to get resident cigarettes. Resident #4 was purchased a book (lockbox), and the card was not found, and the card was placed on hold. On [DATE], the social worker contacted Resident #4's RP as she was able to see purchases while Resident #4 was in the hospital ([DATE]-[DATE]). The report indicated the RP had not seen nor had made purchases for Resident #4. The provider investigation report indicated Resident #4 did not have any visitors during the months of May or June. The investigation report indicated the police investigator had met with Resident #4 in private and noted Resident #4 did not know what happened to her card. The Provider Investigation Report indicated a replacement was requested. Resident #4 was to be the direct payee, and a lockbox was purchased for Resident #4's card to be kept in the business office for her use with consent. The Provider Investigation Report indicated an in-service was provided on misappropriation. The Provider Investigation Report indicated on [DATE], the ADM was made aware an investigator would be taking over the case and was requesting footage from transactions on date known from withdrawal sites. Record review of an in-service topic titled Misappropriation dated [DATE] indicated 14 staff members were in-serviced. The in-service summary provided indicated to be mindful that if a resident has reported a loss of personal item.not use any of the resident's personal property.cannot use resident's phone, money.must protect residents and safeguard their personal.contact the administrator.In the event you have knowledge or feel someone was misusing resident's property.resident having issues protecting their property. Misappropriation of Resident Property Inservice Training indicated. misappropriation of resident property was a serious violation that must be addressed in in-service training to ensure staff understand their legal and ethical responsibilities. Definition and Legal Scope. Federal Regulations define misappropriation as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. This applies to any individual providing care in a facility that participates in Medicare and Medicaid, including full-time staff, part-time employees, contractors, volunteers, and agency workers. There was no facility policy or sign-in sheet attached to the in-service. The signatures were signed on the summary topic misappropriation. Record review of employee file for CNA J revealed he was a contracted employee. CNA J was an employee of a contracted platform service. There were no previous employee misconduct reports identified on the service platform and CNA J was current with training and licensure. Record review of a Report of Certified Nursing Assistant Misconduct dated [DATE] indicated CNA J had no misconduct. During an interview on [DATE] at 10:24 AM, the Police Investigator met with ADM, Surveyor, and Program Manager. The Police Investigator was able to review footage of an alleged perpetrator from the convenient store. The alleged picture was identified as contracted employee CNA J. The Police Investigator said he was going to get a warrant and contact the alleged suspect, CNA J. During an interview and record review on [DATE] at 10:46 AM, the DON was asked for the employee file for contract employee, CNA J. The record review of the contractor platform indicated the background check was cleared by Texas Department of Public Safety The DON said when she used the contractor platform to schedule a staff member, she said she may never meet the employee. The DON said the contractor platform completed all the background checks for the employee. During an interview on [DATE] at 1:12 PM, the ADM brought the five-day investigation report. The ADM said Resident #4 had her bank card in a lock box in her room. The ADM said she would purchase her cigarettes for Resident #4 using her debit card. The ADM had requested the bank card code number on [DATE] and went to her lock box to obtain the card and the card was not in Resident #4's lockbox. The ADM said Resident #4 was sent to the hospital on [DATE] and admitted on [DATE]-[DATE]. The ADM said purchases were made during and after Resident #4's hospitalization. The ADM said Resident #4's RP voiced that she had not gone to see Resident #4 nor made purchases for Resident #4. The ADM said Resident #4 did not have any known visitors in May or June. The ADM said the Investigator was taking over the investigation and making contact to obtain footage from transactions from ATM. Attempted phone interview on [DATE] at 2:13 PM with RP for Resident #4. Voicemail was full and unable to leave a message. No return call by the end of investigation. During a record review on [DATE] at 11:35 AM, CNA J's background check was completed on [DATE] and expired on [DATE]. CNA J completed a post training test for Abuse, Neglect and Exploitation that expired on [DATE]. Background checks and trainings were completed annually by the independent contractor to remain eligible to bid on shifts. During a phone interview on [DATE] at 4:41 PM, CNA J said he had worked for the platform contractor for 3-4 years. CNA J stated he had worked at the facility but could not recall the last time he worked. CNA J stated he had training annually over Abuse, Neglect, and Exploitation. CNA J refused to answer additional questions and hung up when asked additional questions. During a phone interview on [DATE] at 12:32 PM, the Police Investigator called the ADM while at facility and was placed on speaker phone with his acknowledgement. The Police Investigation said the CNA J admitted he made the transactions with Resident #4's debit card. The investigator said CNA J wanted to repay Resident #4 if she would drop the charges. The ADM did not feel the resident would be able to make decisions because of her intermittent confusion. The Police Investigator said he was going to come to the facility to speak with Resident #4 to determine how she would like to proceed. The Police Investigator also mentioned that the facility could represent her, but he was going to contact the District Attorney. During a phone interview on [DATE] at 12:45 AM, the Account Manager K for the platform contractor, ADM, and Surveyor on speaker phone with acknowledgement of all parties. The Account Manager K provided CNA J's address and telephone number on file. The Account Manager K said she was alerted when the ADM had called asking questions about the background check informing them that State was in the building. The Account Manager K said the call about the background automatically alerts the platform when an inquiry happens even if no information was provided regarding the allegation and potential perpetrator. The Account Manager K said the platform placed a pause on CNA J's account prompting the employee could not work through their system. The Account Manager K said anytime there was an investigation or allegations, the facility should report to them alerting the platform, so the staff member does not work in other areas until investigation was completed. The ADM wanted the investigator to call platform contractor to notify them of the confirmed reports. During an interview on [DATE] at 1:38 PM, the Police Investigator, ADM and Surveyor went to Resident #4's room. Resident #4 was provided options from the Police Investigator to determine how she wanted to proceed. Resident #4 told the Police Investigator she wanted the perpetrator to go to jail, and she wanted to press charges. The Investigator told Resident #4 she had 3 options:Drop charges and perpetrator wanted to pay her back her funds.He gets arrested for being a thief.Or he goes to jail and pays reinstitution.Resident #4 said she wanted perpetrator to go to jail because she did not want this to happen to anyone else. Resident #4 said she was stuck here and not everybody was her. Resident #4 said she wanted him in jail, so he does not do it again. Resident #4 said the perpetrator was hurting people who have bills to pay. Resident #4 said at least you caught him. During an interview on [DATE] at 1:49 AM, the Police Investigator said the perpetrator took the card after finding it in the laundry and he took the card from there. Allegedly, CNA J left work early on [DATE] at 5:00 am and went to gas station and took out $40. The Police Investigator said CNA J used his own debit card and took out $400 so it would not look suspicious. The Police Investigator said he would be writing his report and issuing a warrant. The Police Investigator stated that he would have his report completed and we could request records when he was completed. During an interview on [DATE] at 11:27 AM, Resident #4 said she recalled taking her debit card out of her lockbox and laying it on top of her lockbox inside her bedside drawer. Resident #4 said she often went out to smoke and came back, and it was gone. Resident # 4 said she did not realize her card was missing for a couple of days and said she used her debit card to purchase her cigarettes. Resident #4 said she kept her pin number in her mind. Resident #4 denied giving out her pin number and denied having the pin number written down. Resident #4 said she wanted the perpetrator in jail and said the person should not have stolen from her. Resident #4 said she felt hurt knowing someone had stolen from her. Resident #4 denied feeling fearful. Resident #4 wanted the perpetrator to know what he did was wrong. Resident #4 did not know who the perpetrator was. Resident #4 said she felt the facility was doing everything possible to protect her. Resident #4 said the facility was now storing her debit card. Resident #4 felt her debit card was taken while she was out on a smoke break. Resident #4 said he could do to someone else what he did to her and steal $1600. During an interview on [DATE] at 12:10 PM, CMA L said she held many roles as a staff coordinator, CMA, worked PRN for transportation and ordered supplies for central supply. CMA L said she was familiar with the situation because the police investigator had come to the facility to interview her. CMA L said she was able to identify CNA J. CMA L said she did not know how CNA J was able to obtain Resident #4's debit card and she did not know she had one missing until the police came in. CMA L said CNA J was a talkative person and nice. CMA L said CNA J worked one shift in May and she thought one time in March. CMA L said he was not a regular staff member. CMA L said she had not observed any changes in Resident #4. CMA L said Resident #4 continued to eat well and went outside on her smoke breaks. CMA L said Resident #4 was not a talkative resident. CMA L said she had been in-serviced on abuse, neglect, and exploitation. CMA L said the ADM was the Abuse Coordinator and she would report to her immediately or contact the ADON, or DON, if she could not reach the ADM. CMA L said all staff were responsible for ensuring residents' property was safe and secure. CMA L said it could negatively impact a resident because the residents may not trust staff anymore and this was their home. CMA L said it would be like someone breaking into your home. During an interview on [DATE] at 12:29 PM, RN M said she had been in-serviced on abuse, neglect, and exploitation. RN M said she had not received any reports of missing money or debit cards. RN M said she would report to the ADM if a staff member or resident reported missing property. RN M said she would report it immediately. RN M said she did not know who locks stuff up at the facility. RN M said she would be responsible for ensuring the resident belongings were secure in their rooms. RN M said a resident may feel violated and may not feel safe due to lack of trust with staff. During an interview on [DATE] at 1:27 PM, ADON E said the ADM had mentioned Resident #4's missing debit card in a morning meeting one day last week. ADON E said she did not have anyone who was suspected of taking the card. ADON E said she did not know the exact date of the missing card. ADON E said the ADM called the police and reported it. ADON E said the police took statements and did follow-ups. ADON E said the facility staff did not do any in-services with the staff. ADON E said she was not sure when the last in-service was for abuse, neglect, and exploitation. ADON E said abuse, neglect, exploitation should be reported immediately to the ADM who was the Abuse Coordinator. ADON E said everybody was responsible for ensuring the resident belongings were safeguarded. ADON E said a resident could be left with nothing if someone took all their money and it could make the resident feel violated. During an interview on [DATE] at 1:00 PM, the SW said she visited with Resident #4 after her debit card was missing on [DATE], the day she found out it was missing. SW said Resident #4 was upset. Resident #4 had been in the hospital and could not recall if she had taken it to hospital. SW said she had visited Resident #4 on Friday and told her that the facility was working on it. SW said Resident #4's debit card was being stored in a lock box in the business office. SW said the resident knew the pin code and ADM knew the pin as well. The SW said the ADM had used it to buy Resident #4's cigarettes. The SW said the ADM was paying for the cigarettes herself. The SW said she had to identify the pin number for the missing card to get a new card. The SW said it was the same number, so she attempted the same number. The SW did not know if Resident #4 had given out her pin number. The SW said Resident #4 was estranged from RP because of the card in the past. The SW said she had accused her RP of stealing from her, so the RP had given the debit card back to her. The SW said the facility wanted to keep the debit card locked in the business office, but Resident #4 refused and demanded the ability to keep her card with her. The SW said the resident was responsible for ensuring the debit card was secure if they want to keep it in their possession. The SW said it could negatively impact the resident because she was sure she was upset. During an interview on [DATE] at 1:11 PM, the Business Office Manager said the facility was working on becoming Resident #4's payee. The Business Office Manager said Resident #4's new debit card had not arrived, and the lockbox was purchased to be kept in the office. The Business Office Manager said the new card would go into a lock box and then go into another locked cabinet in her office. She said Resident #4 would come to her to get money from her trust fund. The Business Office Manager said Resident #4 had made past allegations of RP. She said at admission, the facility recommended families to take anything of value home or residents have lockboxes. She said inventory was taken at admission. The Business Office Manager said the nurse who received any reports of missing property should report immediately to the ADM who was the Abuse Coordinator. The Business Office Manager said it could make a resident not feel safe if their belongings were taken. During a phone interview on [DATE] at 2:00 PM, LVN N said she has been a platform contractor since [DATE]. LVN N said she did have training over abuse, neglect, and exploitation. LVN N said she had worked at the facility a hand full of times. LVN N said she was unaware of Resident #4 missing a debit card or money. LVN N said she had never observed Resident #4 giving her debit card to anyone. LVN N said she worked on [DATE]. LVN N said she had worked with CNA J and described him as tall and skinny. LVN N said she had thanked him for his great attitude. LVN N said she would report to the DON immediately if she suspected abuse, neglect, or exploitation. During an interview on [DATE] at 2:47 PM, the DON said the ADM was responsible for ensuring the residents' funds were secure and getting a lock box for the residents if they want to keep items/money/card in their room if they choose to. The DON said she expected the staff to report to ADM immediately any missing money or items. The DON said it could negatively impact a resident by making them feel unsafe and emotional. The DON said a resident could feel violated. The DON said the facility did an in-service on abuse, neglect, and exploitation. The DON said she could not think of any other actions taken to prevent missing money or items. The DON said CNA J would not be coming back and was on the do not return list. During an interview on [DATE] at 2:53 PM, the ADM said she expected the staff to report allegations of abuse, neglect and exploitation and should report when they were made aware. The ADM said she did an in-service with all staff and later said not with the whole team. The ADM said this incident could negatively impact a resident in so many ways such as not feeling their personal belongings were protected. The ADM said the entire facility team staff were responsible for ensuring personal belongings were protected. The ADM said the perpetrator was banned from the facility. The ADM said the facility highly encouraged residents to allow them to help manage their personal funds. Review of an Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy dated [DATE] indicated, .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation.1. Protect resident abuse, neglect, and exploitation prevention program consist of facility-wide commitment and resource allocation to support the following objectives: .protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and any other individuals. 2. Develop and implement policies and protocols to prevent and identify.3. Ensure adequate staffing and oversight.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive, or emotional problems. Record review of an Abuse Prohibition Policy and Procedure, undated indicated Facility is committed to providing a safe and respectful environment for all residents. It is the policy of this facility to prohibit all forms of abuse, neglect, exploitation, and misappropriation of their property. promptly investigate, report, and respond to allegations.Policy Statement.All resident has the right to be free from abuse.maintains zero tolerance for any form of abuse or retaliation.applies to all staff, contractors, volunteers, visitors, and anyone entering the facility. Definitions.Abuse.Neglect.Exploitation.Misappropriation of Resident property. Prevention.All employees receive training on abuse prevention, recognition, and reporting.pre-employment background checks, reference verification, and registry checks are conducted on all employees. 2. Reporting.any staff member, volunteer, contractor who witnesses, suspects, or is informed of abuse must immediately report.must be made to the Administrator or designee. Anonymous reports are permitted.3. Investigation.the facility will initiate an investigation immediately.Abuse coordinator will lead the investigation and document findings. accused employee may be suspended pending the outcome of the investigation.4. Protection and Residents.residents involved in allegation will be safeguarded.supportive services.5. Corrective Action.substantiated cases of abuse will result in immediate disciplinary action.required retraining, policy revision, or systemic changes identified.the facility will review each incident.Abuse Coordinator.ensure oversight and accountability.receiving, documenting, and tracking all allegations of abuse, neglect, exploitation, and misappropriation.ensuring immediate protection measures.coordinating and overseeing investigation in collaboration.ensuring timely reporting, maintaining complete investigation files and tracking trends.leading staff education on abuse prevention and reporting requirements.

Based on interview and record review, the facility failed to conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 4 residents (Resident #21) reviewed for comprehensive assessments and timing. The facility did not ensure Resident #21's admission MDS assessment was completed within 14 days of admission. Resident #21 was admitted to the facility on [DATE] and her comprehensive care plan was not completed until 6/17/26. This failure could place residents at risk of not having their needs identified and met.Findings included: Record review of Resident #21's face sheet dated 6/17/26 indicated she was [AGE] years old and admitted to the facility on [DATE] with diagnoses which included cerebral infarction due to embolism of other cerebral artery (a type of ischemic stroke) and unspecified dementia (a clinical or diagnostic classification used when a patient exhibits a clear decline in cognitive abilities such as memory loss or problem-solving). Record review of Resident #21's comprehensive MDS assessment, with an ARD of 6/8/26, indicated in Section A0310 it was an admission assessment (required by day 14). The MDS assessment for Resident #21 indicated in Sections: A0310, A1005, A1010, A1110, A1805, J2000, O0110 and V0200 were incomplete. The MDS assessment in Section Z0500 was not signed and incomplete on 6/17/26, which indicated the MDS assessment for Resident #21 was a day late. During an interview on 6/17/26 at 12:20 PM, the MDS Nurse stated she did the MDS assessments. She stated she was not finished with Resident #21's MDS. She stated she had 14 days from Resident #21's admission date to have the MDS assessments completed. She stated her goal was to have MDS assessments completed that day. She stated yesterday (6/16/26) was the 14th day and she had not completed the MDS assessments for Resident #21. During an interview on 6/17/26 at 1:57 PM, the Administrator stated her expectations were for MDS assessments to be completed accurately and timely. She stated the facility's MDS Nurse was responsible for the MDS assessments. She stated the risk was a possibility of risk with detail. During an interview on 6/17/26 at 2:25 PM, the Director of Nursing stated she expected the MDS assessments to be done timely and accurately. She stated the MDS Nurse was responsible for the MDS assessments. She stated the risk would be inaccurate billing. Review of Certifying Accuracy of the Resident Assessment Policy dated November 2019 revealed Any person completing a portion of the [NAME] Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. 1. Any health care professional who participates in the assessment process is qualified to assess the medical, function and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge.4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 21 residents reviewed for assessments. (Resident #27) The facility failed to ensure the MDS was appropriately coded for functional limitations in ROM for Resident #27. Resident #27 had bilateral hand contractures. This failure could place residents at risk for decreased quality of care due to inaccuracy of assessments. Findings included: Record review of the face sheet, dated 6/16/26, indicated Resident #27 was an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of the physician's orders, dated 6/16/26, indicated Resident #27 had diagnoses that included: Dementia (decline in mental ability such as thinking, reasoning, and memory severe enough to affect daily life), Aphasia (impaired ability to speak), and Alzheimer's Disease (progressive irreversible brain disorder that slowly destroys memory and thinking skills). Record review of the annual MDS assessment, dated 3/20/26, indicated Resident #27 had short-term and long-term memory problems. The MDS, Section GG0115/Functional Limitations in Range of Motion, indicated Resident #27 had no functional limitation in range of motion in her upper extremities (shoulder, elbow, wrist, hand). The MDS indicated she was dependent on staff for eating, toileting, dressing and personal hygiene. Record review of the undated care plan indicated Resident #27 had cognitive impairment related to a diagnosis of Dementia/Alzheimer's Disease. The care plan indicated, I have contractures and am at risk for skin breakdown, increased pain from affected areas and injuries, mobility impairment related to functional limitation in ROM. Have contractures of bilateral hands. During an observation on 6/15/26 at 9:26 A.M., Resident #27 was in bed. The head of the bed was raised approximately 40-45 degrees. Both hands were contracted. Her hands were clean and fingernails that were visible were trimmed and not jagged. She did not have hand rolls in her hands. Call light was within reach. During an interview on 6/17/2026 at 1:40 PM, ADON E said MDSs should be marked correctly so nurses knew how to care for a resident and so the care plan was correct. She said for example, if a resident was marked for 1 (impairment on one side) or 0, (no impairment) in Section GG0115/Functional Limitations in Range of Motion, she might assume the resident could brush her own teeth. She said the risk for this section being marked wrong was staff might not know what they needed to do for that resident. She said Resident #27 could not move either hand at all, both hands were contracted. She said Resident #27 should have been coded a 2 in Section GG0115 indicating she had impairment on both sides. During an interview on 6/17/2026 at 1:44 PM, the MDS nurse said she marked Resident #27's GG0115/Functional Limitation in Range of Motion wrong. She said she should have marked that section a 2, which indicated impairment on both sides, but she had marked it 0 indicating no impairment. The MDS nurse said she knew Resident #27 had bilateral hand contractures but marked it wrong. She said she would do an MDS correction. During an interview on 6/17/2026 at 1:57 PM, the ADM said her expectations were for the MDSs to be completed accurately and timely. She said the MDS nurse was responsible for the MDS assessments. During an interview on 6/17/2026 at 2:25 PM, the DON said she expected MDSs to be completed timely and accurately. The DON said the MDS Coordinator was responsible for the MDS assessments. She said the risk would be inaccurate billing. Record review of a facility policy titled, Certifying Accuracy of the Resident Assessment, dated November 2019, provided by the ADM indicated: Policy StatementAny person completing a portion of the Minimum Data set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and Implementation 1.Any healthcare professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. 2.Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. 3. The information captured on the assessment reflects the status of the resident during the observation ( look-back) period for that assessment. Different items on the MDS may have different observation periods. 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse.

Based on observation, interview, and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease in ROM for 1 of 21 residents reviewed for rmobility. (Resident #27) The facility failed to ensure Resident #27 had contracture prevention devices in place for treatment of her right-hand and left-hand contractures. These failures could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures. Record review of the face sheet dated 6/16/26 indicated Resident #27 was an [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of the physician's orders, dated 6/16/26, indicated Resident #27 had diagnoses that included: Unspecified Dementia (decline in mental ability such as thinking, reasoning, and memory severe enough to affect daily life), Aphasia (impaired ability to speak), Alzheimer's Disease (progressive irreversible brain disorder that slowly destroys memory and thinking skills) and Gastrostomy Status (presence of a surgically created opening in the stomach that allows a feeding tube to be inserted directly through the abdominal wall, primarily used for long term nutritional support). There were no physician's orders addressing her bilateral hand contractures. Record review of the annual MDS assessment, dated 3/20/26, indicated Resident #27 had short-term and long-term memory problems. The MDS Section Functional Limitations in Range of Motion indicated Resident #27 had no functional limitation in range of motion in her upper extremities (shoulder, elbow, wrist, hand). The MDS indicated she was dependent on staff for eating, toileting, dressing and personal hygiene. Record review of the undated care plan indicated Resident #27 had cognitive impairment related to a diagnosis of Dementia/Alzheimer's Disease. Further review indicated, I have contractures and am at risk for skin breakdown, increased pain from affected areas and injuries, mobility impairment related to functional limitation in ROM. Have contractures of bilateral hands. An update to the care plan, dated 3/9/26, indicated, Therapy states no change in contracture of hands. I am not appropriate for therapy services. No odor, or moisture, and no further contracture since last OT assessment. An update to the care plan, dated 6/12/26, indicated, Therapy states no change in contracture of hands. I am not appropriate for therapy services. No odor, or moisture, and no further contracture since last OT assessment. The goal for her contractures was, Contracture management will be effective as evidenced by no deterioration in current level of contracture this quarter, pain will be controlled within one hour of intervention and no injuries will occur through next review date. I will have no decline in current level of functional mobility through the next review date. Interventions for contractures included: Encourage use of mobility devices if needed and per MD orders. Apply splints as ordered. Record review of the MAR/TAR, dated May 2026 and June 2026, did not indicate any type of treatment for Resident #27's bilateral hand contractures. Record review of a Multidisciplinary Screening Form, dated 3/9/26, indicated Resident #27 had a quarterly PT, OT, and ST evaluation. The DOR signed the form and indicated, No change in contracture of hands. Patient not appropriate for therapy services. No odor, or moisture, no further contracture than last assessment. Record review of a Multidisciplinary Screening Form, dated 6/12/26, indicated Resident #27 had a quarterly PT, OT, and ST evaluation. The DOR signed and form and indicated, No change in condition. No further contracture. No odor. No therapy needed at this time. During an observation on 6/15/26 at 9:26 A.M., Resident #27 was in bed. The head of the bed was raised approximately 40-45 degrees. Both hands were contracted. Her hands were clean and fingernails that were visible were trimmed and not jagged. She did not have hand rolls(such as a rolled wash cloth to prevent hands from closing further) in her hands. Call light in reach. She had a feeding tube running with Isosource, 1.5 calories at 50 ml/hr (dated 6/15/26), and water dated 6/15/26 with a water flush of 35 ml every hour. Observation indicated the feeding tube syringe was secured in a plastic bag, dated 6/15/26. During an observation on 6/15/2026 at 1:48 PM, Resident #27 was lying in bed. HOB was elevated approximately 40 degrees. She had no hand rolls in either hand. She was not interviewable. During an interview on 06/15/2026 at 3:08 PM, OTA C said the last time Resident #27 had OT was in 2025. OTA C said Resident #27 was discharged in March 2025. She said Resident #27 currently used rolled wash cloths in her hands for contracture management. She said the aides were diligent about putting in the hand rolls for a moisture barrier and staff trimmed her nails. OTA C said Resident #27 was managed care only, and because of that, she only qualified for OT yearly. OTA C said she was not sure why Resident #1 had not received OT in 2026. She said the DOR was not available at this time, but she would be able to answer that question. During an observation on 6/16/2026 at 9:50 A.M., Resident #27 was lying in her bed. HOB was up approximately 40 degrees. Her hands were clean and her nails were trimmed. She had no hand rolls in either hand. During an interview on 6/16/26 at 9:55 A.M., CNA F said she did not put hand rolls in Resident #27's hands and was not responsible for doing that. She said she had not ever seen hand rolls in Resident #27's hands. During an interview on 6/16/26 at 9:58 A.M., LVN G said she cleaned Resident 27's hands and cut her fingernails. She said it had probably been a week since she put hand rolls in Resident #27's hands. She said she did not document when she put the hand rolls in her hands. She said when she did put them in, she would leave them in for 2-3 hours then remove them. She said she clipped her nails as needed and washed her hands each shift or as needed. LVN G said the CNAs did not put hand rolls in residents' hands, only the nurses. She said the risk of not using rolls in Resident #27's hands were that the contractures could get worse, but they had not. She said she knew the contractures had not gotten worse because she saw her, cleaned her hands and was familiar with her. She said the last time she cut Resident #27's fingernails was Sunday (6/14/26). She said she did not document when she cut her fingernails or cleaned/washed her hands. During an interview on 6/16/2026 at 10:05 A.M., the DOR said they followed the MDS schedule when screening residents for therapy; therefore, screenings were done quarterly. The DOR said the MDS nurse gave her a list of MDS's that were due and she evaluated the residents on that list. She said she provided evaluations for Resident #27, dated 3/9/26 and 6/12/26. She said Resident #27 was not appropriate for therapy. She said therapy had a meeting with nurses (DON) in March of 2026. She said she thought she remembered that they (DON and DOR) decided no hand rolls were needed due to her contractures not changing. She said the results of the meeting was what was in her care plan indicating she did not currently need hand rolls or therapy. During an interview on 6/16/2026 at 10:50 A.M., the DON said in March of 2026 therapy reviewed Resident #27's evaluations, and it was determined by therapy, her contractures had not declined, and hand rolls were not needed. She said no one at this time was supposed to be putting hand rolls in Resident #27's hands. During an interview on 6/16/2026 at 11:21 A.M., the DON said they had a care plan meeting on 3/26/26 and there were no changes with Resident #27's bilateral hand contractures. She said there was no need for hand rolls or therapy at that time. She said therapy evaluated her quarterly and if there were any changes they would look at it again. The DON said she agreed with the care plan. During an observation on 6/17/2026 at 8:27 A.M., Resident #27 was in bed with HOB up approximately 40 degrees. Her hands were clean and her fingernails were trimmed. There were no hand rolls in her hands. During an interview on 6/17/2026 at 8:35 A.M., RN D said if a resident had contractures, it was important to keep rolls in their hands to prevent contractures from getting worse. She said not having rolls in a resident's hands could cause the contractures to worsen, or cause the resident's fingernails to dig into their hands and break the skin, which could cause wounds. During an interview on 06/17/2026 8:49 A.M., the ADM said the policy she provided was the only one they had regarding contractures. During an interview and observation on 6/17/2026 at 10:17 A.M., ADON E said if a resident had contractures and therapy indicated they needed hand rolls to prevent contractures from getting worse they should have them. However, she said if a nurse felt like a resident needed hand rolls for contractures, that nurse should care plan it so that all staff knew to put hand rolls in. She said she wanted to look at Resident #27's hands. ADON E went to Resident #27's room and she assessed Resident #27's hands. ADON E said Resident #27 should have hand rolls in her hands because they were closed all the way and there was a risk of the contractures getting worse and also a risk of wounds if her fingernails dug into her skin. During an interview on 6/17/2026 at 10:23 A.M., the ADM said per the care plan, hand rolls had not made a difference for Resident #27. She said therapy evaluated her quarterly and if there were any changes in her contractures, they would address it. The ADM said it would make sense that the contractures would get worse if not treated but not with Resident #27, because her hands were not changing and they were evaluated by therapy. Record review of the facility policy titled, Resident Mobility and Range of Motion Policy, dated 2001, provided by the ADM indicated: Policy Statement 1.Residents will not experience an avoidable reduction in range of motion (ROM).2.Residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in ROM.3.Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable. Policy Interpretation and Implementation 1.As part of the resident's comprehensive assessment, the nurse will identify the resident's:a.current range of motion of his or her joints.c.limitations in movement or mobility;d.opportunities for improvement; ande.previous treatment and services for mobility. 2. As part of the comprehensive assessment, the nurse will also identify conditions that place the resident at risk for complications related to ROM and mobility, including:a.pain;b.skin integrity issues;c.muscle wasting and atrophy.e.contractures; [NAME].other complications that could cause or contribute to immobility, impaired ROM. 3.During the resident's assessment, the nurse will identify the underlying factors that contribute to his or her range of motion or mobility problems, if any, including:a.immobilization (bedfast, chair or wheelchair usage);b.neurological conditions cerebral palsy, cerebral-vascular accident , etc.);c.conditions in which movement may lead to pain;and/ord.conditions that limit or immobilize movement of limbs or digits (e.g. splints). 4. The care plan will be developed by the interdisciplinary team based on the comprehensive assessment and will be revised as needed. 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion.8.Documentation of the resident's progress toward the goals and objectives will include attempts to address any changes or decline in the resident's condition or needs.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents (Resident #7) reviewed for infection control. The facility failed to ensure CNA B sanitized her hands after removing dirty gloves and applying clean gloves while providing catheter care and incontinent care for Resident #7 on 6/16/26. This failure could place residents at risk for cross contamination and the spread of infection.Findings included: Record review of Resident #7's face sheet, dated 6/16/26, reflected a [AGE] year-old female, admitted [DATE] and readmitted [DATE]. Resident #7 had diagnoses which included: chronic diastolic (congestive) heart failure (occurs when the heart's main pumping chamber (left ventricle) becomes stiff and cannot relax to fill with blood properly), retention of urine (the inability to fully empty the bladder) and need for assistance with personal care and chronic kidney disease stage 3B (the kidneys have moderate to severe damage, operating at roughly 30% to 44% of their normal capacity). Record review of Resident #7's comprehensive MDS assessment, dated 4/6/26, reflected Resident #7 was understood and understood others. Resident #7's BIMS score was a 10, which indicated moderately impaired cognition. Resident #7 was dependent on staff for ADLs. Resident #7 was always incontinent of bowel and had a catheter for urinary continence. Record review of Resident #7's care plan, revised dated 6/2/26, reflected Resident #7 required assistance with ADLs. Resident #7 was transferring herself without assistance. The intervention included staff would assist Resident #7 with all ADL's unable to be performed independently. Record review of Resident #7's care plan, dated 6/2/26, reflected Resident #7 required enhanced barrier precautions related to one or more of the following: indwelling catheter and wound. The interventions included to gather all needed supplies and material, clean hands correctly, and put on a gown and gloves. Record review of Resident #7's care plan, dated 6/2/26, reflected Resident #7 had bladder incontinence with the presence of catheter indwelling for the following diagnosis: urinary retention. Resident #7 manipulated her catheter and would drag it on the ground versus using her privacy bag. The intervention included providing catheter care per Medical Director orders. Record review of Resident #7's physician's order summary report, dated 6/16/26, reflected urinary catheter care every shift, dated 3/31/26. Record review of CNA B's Hand Washing and Perineal Care Competency Assessments, dated 12/18/25, indicated she was checked off on all skills and signed by ADON H. During an observation on 6/16/26 at 11:14 A.M., CNA B was accompanied by RN A for catheter care and incontinent care for Resident #7. CNA B performed catheter and incontinent care for Resident #7. CNA B removed her dirty gloves and applied clean gloves without sanitizing her hands, then she proceeded to apply a clean brief and clean pants to Resident #7. During an interview on 6/16/26 at 11:28 A.M., CNA B stated she knew she forgot to sanitize her hands between glove change. She stated she had the sanitizer on the table, but she was nervous. She stated when going from dirty to clean she was supposed to sanitize her hands between glove changes. She stated gloves could have permeation(the process by which a substance (like a gas, liquid, or vapor) penetrates, spreads through, or passes completely through a solid material or space), because there were many things that could be transferred through gloves that could not be seen by the naked eye. She stated improper hand hygiene could cause cross contamination. During an interview on 6/16/26 at 11:32 A.M., RN A stated when performing catheter care and incontinent care she expected the CNAs to change their gloves and sanitize their hands when going from dirty to clean. She stated she observed CNA B when she failed to sanitize her hands after removing the dirty gloves, but she had already started the next step before she could intervene. She stated she was not sure who was responsible for ensuring the staff were checked off for proficiency. She stated a negative effect of improper hand hygiene was cross contamination. During an interview on 6/17/26 at 1:45 PM, ADON E stated she expected the staff to their sanitize hands when going from dirty to clean and after a glove change. She stated it was the infection prevent list and she was responsible for staff using proper hand hygiene. She stated the risk of improper hand hygiene was infection and the spread of bacteria. During an interview on 6/17/26 at 1:57 PM, the Administrator stated her exceptions were for staff to sanitize their hands between glove changes when going from dirty to clean. She stated the risk was possible infections. During an interview on 6/17/26 at 2:25 PM, the Director of Nursing stated she expected staff to sanitize when going from dirty to clean and between gloves changes, during incontinent and catheter care. She stated the Infection Preventionist was responsible for ensuring staff were using proper hand hygiene techniques. She stated the risk was infection. Record review of the facility's policy titled, Handwashing/ Hand Hygiene, dated December 2025, indicated. Hand hygiene is the primary means for preventing healthcare-associated infections (HAIs) and the transmission of multidrug-resistant organisms (MDROs). This facility requires strict adherence to evidence-based hand hygiene practices (as described in this policy) for all personnel, including licensed, contracted, therapy, dining, housekeeping: volunteers, and students. 1. All personnel are provided with hand hygiene training upon hire and annually thereafter. Hand hygiene competency of staff is measured, including through return demonstrations to verify technique. 1. Hand hygiene is indicated: h. after glove removal. Record review of the facility's policy titled, Perineal Care, dated February 2018, indicated. The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.

Based on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider when an antibiotic was used despite criteria, to determine the the appropriate use of an antibiotic for 1 of 5 residents reviewed for antibiotic use (Resident #32). The facility failed to ensure Resident #32 did not receive Bactrim 800-160mg (an antibiotic used to treat a variety of bacterial infections) for prophylactic antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.Findings included: Record review of Resident #32's face sheet, dated 06/17/26, reflected she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills) and multiple sclerosis (a chronic autoimmune disease of the central nervous system). Record review of Resident #32's quarterly MDS assessment, dated 05/08/26, reflected that she had a BIMS score of 09, which indicated moderate cognitive impairment. She was usually able to make herself understood and she was able to understand others. Record review of Resident #32's Order Summary Report, dated 06/16/26, reflected the following order:*Bactrim oral tablet 800-160 mg, give 1 tablet by mouth one time a day for prophylactic indefinitely. The start date was 03/12/26. There was not an end date. During an interview on 06/17/26 at 11:22 AM, ADON E said they were giving Resident #32 the Bactrim medication for a UTI preventative. She said they had to keep putting her on IV antibiotics to treat recurrent UTIs. She said they did not follow any criteria for that, but they just followed the doctor's order. She said they did not have a documented rationale for the antibiotic, and they did not document other things they had tried. She said it had not been brought up in a pharmacy consultant review. During an interview on 06/17/26 at 02:11 PM, the DON said Resident #32 had recurrent UTI's. She said she did meet the McGeer's criteria (standardized definitions used for infection surveillance in long-term care and nursing facilities) for having a prophylactic antibiotic. During an interview on 06/17/26 at 02:25 PM, the Administrator said she expected the nursing staff to follow orders. She said the risk to Resident #32 was a possibility of change of condition. Record review of the Facility's policy, Antibiotic Stewardship - Orders for Antibiotics, last revised December 2016, reflected: .3. Appropriate indications for use of antibiotics include:a. criteria met for clinical definition of active infection or suspected sepsis; andb. pathogen susceptibility, based on culture and sensitivity, to antimicrobial (or therapy begun while culture is pending).

Based on observations, interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for quality of care.1.The facility failed to ensure Resident #1 was assessed for injury following a fall from bed on 4/12/2026 during incontinent care. Resident #1 was discovered to have a tibia/fibula fracture on 4/19/2026.2. The facility failed to ensure Resident #1's care needs were addressed for bed mobility and incontinent care.3. The facility failed to transfer Resident #1 back to bed with a Hoyer lift instead of grabbing her arms and legs and putting her back in bed. An IJ was identified on 4/27/2026. The IJ template was provided to the facility on 4/27/2026 at 4:26pm. While the IJ was removed on 4/28/2026, the facility remained out of compliance at a scope of isolated and a severity level of No actual harm with the potential for more than minimal harm that is not immediate jeopardy because (e.g.) all staff had not been trained on skin assessments, Kardex, Bed Mobility/Repositioning/Incontinent care, Post Fall Assessments, and Notifying Nurse with Changes.These failures could place residents at risk for not receiving appropriate care and treatment and or decline in their health. Findings included:Record review of an admission Record for Resident #1 dated 4/27/2026 indicated she was an [AGE] year-old female that admitted to the facility on [DATE] with diagnoses that included: hemiplegia affecting left nondominant side (unable to move one side of the body), chronic obstructive pulmonary disorder (lung disease), convulsions (involuntary shaking or muscle spasms).Record review of a Quarterly MDS Assessment for Resident #1 dated 3/13/2026 indicated she was not assessed for cognition due to being rarely or never understood. Staff Assessment for mental status indicated Resident #1's BIMS was 03 which indicated severe cognitive impairment. She was dependent on staff for transfers, bed mobility, and hygiene.Record review of a care plan for Resident #1 initiated on 3/03/2021 indicated: ADLs assistance needed, I require total assistance with ADL's with interventions that included: Staff will assist me with all ADL's unable to perform independently.Record review of a Care plan for Resident #1 initiated on 10/23/2023 indicated: I require a Hoyer left for transfers due to immobility/paralysis with interventions that included: Staff x2 for transfers.Record review of a Care plan for Resident #1 initiated on 3/03/2021 indicated Potential for injury related to history of falls and is at risk for further fall related to: cognitive impairment safety awareness, and due to frequently moving around in my bed and chair after being repositioned. Interventions included: Enlist family input regarding fall history and possible factors to help decrease falls. Ensure staff are aware of safety needs of the resident. Keep bed in lowest position with brakes locked. Review continued need for safety devices/fall risk factors per policy.Record review of facility incident report for Resident #1 dated 4/12/2026 at 3:55pm written by LVN D indicated: Resident #1 was lying on the floor on her back next to bed. CNA A and LVN E present. No signs or symptoms of distress or discomfort or pain noted. Immediate Action taken: Assisted up with 2 staff members onto bed and checked for injuries with none noted and incontinent care given. CNA A statement: While turning resident to give incontinent care, resident started rolling off side of bed, I jumped onto bed and held onto resident to prevent her falling completely onto floor. Resident knees did touch the floor. I laid resident on floor and called for assistance. Record review of Nursing Progress Notes for Resident #1 dated 4/12/2026 at 4:50pm written by LVN D indicated: CNA reported while turning resident to give incontinent care, resident started rolling off side of bed, I jumped onto bed and held onto resident to prevent her falling completely onto floor. Resident knees did touch the floor. I laid resident on floor and called for assistance. Writer entered room and cna and another nurse was present and writer checked resident for injuries then resident assisted back into bed x2. Again, checked for injuries. Nonenoted, but did note blanchable redness on lateral right arm. Incontinent care given. Notified residents sister, MD and DON and hospice nurse of incident. Vital signs 97%-97.6-16-118/73(LR)-72. Will continue to monitor. Record review of hospice visit note for Resident #1 dated 4/13/2026 at 8:50am written by Hospice RN G indicated Resident #1 had mild pain as evidenced by facial grimacing using the painad scale (pain scale used in advanced dementia) with a score of 2. Resident #1 was at high risk for falls. Record review of Skin Assessment for Resident #1 dated 4/15/2026 at 1:57pm completed by LVN D indicated that Resident #1 had no alterations in skin integrity noted. Record review of hospice visit note for Resident #1 dated 4/16/2026 at 11:47am written by Hospice RN G indicated Resident #1 had mild pain as evidenced by facial grimacing using the painad scale with a score of 2. Resident #1 was at high risk for falls. Record review of Nursing Progress Notes for Resident #1 dated 4/19/2026 at 5:37am written by RN J indicated: Patient observed with 1+ edema to right foot, pedal pulses palpable and strong bilaterally yellowish coloring noted to right shin. Hospice notified, awaiting call back from on call nurse. Record review of Nursing Progress Notes for Resident #1 dated 4/19/2026 at 9:20am written by LVN D indicated: Called hospice and spoke with nurse and informed her that resident right lower extremity is warm to touch and resident was flinching to touch. Resident received scheduled pain medication per orders. Pedal pulses were present and right foot continues with swelling. Resident was afebrile. Record review of hospice visit note for Resident #1 dated 4/19/2026 at 2:57pm written by Hospice RN H indicated Resident #1 had mild pain as evidenced by facial grimacing and pulling and pushing away using the painad scale with a score of 5. Resident #1 was at high risk for falls. Resident #1 had bruising and swelling to right lower leg. Hospice RN H called and spoke with Resident #1's family member who reported bruise had been there and related to fall Resident #1 had. Hospice RN H advised RN F to administer as needed dose of pain medication and a verbal order to obtain an xray of the right lower extremity was given. Record review of Radiology Results Report for Resident #1 dated 4/19/2026 at 3:52pm indicated: minimally displaced fracture of the distal tibial shaft and minimally displaced fracture of the mid fibular shaft.Record review of Nursing Progress Notes for Resident #1 dated 4/19/2026 at 3:10pm written by RN F indicated: Resident had scheduled x-ray due to previous fall, pain meds given for pain (resident showed signs of pain). Hospice nurse contacted and results faxed, waiting for phone call to be returned regarding results. Resident currently in bed resting with bed in lowest position and call light within reach. Record review of Physician Progress Note for Resident #1 dated 4/19/2026 at 9:44pm written by the Medical Director indicated: The patient sustained this fracture after a fall last week. Sheis at high risk for surgical complications due to her baseline status, including being bed/chair-bound and unable to follow directions or participate in therapy. The plan is to manage conservatively at the facility. Focus on pain management; increase Norco to TID and add PRN morphine. Record review of facility order summary for Resident #1 dated 4/28/2026 indicated Resident #1's pain medication was increased on 4/19/2026 with a new order for Morphine Sulfate solution 20mg/ml (milligram/milliliter)give 0.5ml by mouth every 4 hours as needed for pain and Norco tablet 5-325mg give 1 tablet by mouth three times a day for pain monitoring. Record review of after visit summary dated 4/21/2026 indicated Resident #1 was seen in office by the Orthopedic physician for a closed fracture of right tibia and fibula. The Orthopedic Physician ordered for Resident #1 to have a splint and to follow up with him in 2 weeks. Review of video footage 1 taken in Resident #1's room on 4/12/2026 from 3:53pm to 3:56pm revealed CNA A was providing incontinent care and turned Resident #1 onto her right side. After turning Resident #1 onto her right side, CNA A let go of Resident #1 to pick up supplies from the floor and Resident #1 rolled off of the bed and onto the floor. CNA A climbed across Resident #1's bed and attempted to pick Resident #1 up by lifting Resident #1 under her arms. CNA A was not able to lift Resident #1 back on to the bed and lowered Resident #1 back down to the floor. CNA A then went to the door and called for the nurse. Review of video footage 2 taken in Resident #1's room on 4/12/2026 untimed revealed LVN E enter the room with CNA A with Resident #1 still lying on the floor. LVN E placed a pillow under Resident #1's head and CNA A and LVN E waited for LVN D to enter the room. Once LVN D entered the room, without assessing Resident #1 for injury LVN E lifted Resident #1 under her shoulders and CNA A lifted Resident #1 under her knees and placed Resident #1 back in the bed. LVN E then left the room. LVN D left the room [ROOM NUMBER] seconds after Resident #1 was placed back in bed without properly assessing Resident #1. CNA A remained in the room with Resident #1 and proceeded with incontinent care. Review of video footage 3 taken in Resident #1's room on 4/12/2026 revealed CNA A continued to provide incontinent care to Resident #1 and turned Resident #1 onto her left side then left the room to gather more supplies. Review of picture 1 of Resident #1's right leg and foot dated 4/13/2026 at 1:44pm indicated swelling to Resident #1's right foot. Review of picture 2 of Resident #1's right leg and foot dated 4/14/2026 at 9:48pm indicated swelling to Resident #1's right foot with possible bruising to the lower right leg. Review of picture 3 of Resident #1's right leg and foot dated 4/17/2026 at 5:44am indicated swelling to Resident #1's right foot with possible bruising to the lower right leg. Review of video footage 4 taken in Resident #1's room dated 4/17/2026 at 1:48pm indicated swelling and yellow discoloration to Resident #1's right lower leg and foot. Review of picture 4 of Resident #1's right leg and foot dated 4/17/2026 at 9:01pm indicated swelling to Resident #1's right foot with bruising and yellow discoloration to the right lower leg. Review of video footage 5 taken in Resident #1's room dated 4/18/2026 at 3:03pm indicated swelling and yellow discoloration to Resident #1's right lower leg and foot. CNA K and CNA L were discussing Resident #1 was showing signs of pain by facial grimacing. Review of video footage 6 taken in Resident #1's room dated 4/19/2026 at 4:19am indicated swelling and yellow discoloration to Resident #1's right lower leg and foot. CNA M was providing care and touched the discolored area to Resident #1's right lower leg, Resident #1 flinched and pulled her leg back from CNA M's touch. During an observation and attempted interview with Resident #1 on 4/27/2026 at 9:00am upon entering Resident #1's room observed Hospice RN G assessing Resident #1. Resident #1 observed to have a blue splint to her right lower leg. Resident #1 was nonverbal due to cognition and not able to answer questions. During an interview on 4/27/2026 at 9:15am CNA O said she had worked at the facility since January 2026. She said Resident #1 was a 2 person assist for all ADLs. She said she had not noticed any discoloration or swelling to Resident #1's right leg. During an interview on 4/27/2026 at 11:46am a Family Member said she had saved the video footage from Resident #1's fall. Said she sent the video footage of Resident #1's fall, to LVN D on 4/12/2026. She said LVN D said she was going to show the video to the Administrator and DON. She said she watched all the video footage from 4/12/2026 through 4/19/2026 and there was no other incident that would have caused Resident #1's fractures. During an interview on 4/27/2026 at 12:50pm the Administrator said she had not seen the videos because she was not supposed to have anything to do with a family's electronic monitoring. She said she knew the videos had been sent to Resident #1's family member that were also employees, which was the housekeeping staff. She said she did not know the video had been sent to LVN D. After watching the videos with the Surveyor, she said she did not have words because she was thinking. During an interview on 4/27/2026 at 1:16pm the DON said she had not seen the videos of Resident #1's fall. After watching the videos with the surveyor, the DON said she felt like Resident #1 was assessed appropriately. She said while Resident #1 was on the floor and the nurses were standing in the room that they could have assessed Resident #1 with their eyes before moving her off the floor. She said CNA A should not have tried to move Resident #1 without first notifying the nurse of the fall. She said she did not see anything inappropriate in the video. During an interview on 4/27/2026 at 6:38pm the Medical Director said he was the medical director at the facility and the medical director of the resident's hospice company. He said he could not determine how the resident had received the fracture to the Tibia/Fibula. He said he had not seen the videos of Resident #1's fall. He said if the facility had notified him that Resident #1 was having any increased pain, swelling or discoloration he would have ordered x-rays at that time. During an interview on 4/28/2026 at 8:40am ADON C said that she had seen about 5-6 seconds of the video of Resident #1's fall on 4/12/26. She said LVN D had the video on her phone and showed it to her about 3 days after the fall. She reviewed the videos with the Surveyor and said if she had seen all of the video footage CNA A would have been terminated that day. She said the CNA should never have tried to pick the resident up and put her back in bed without first notifying the nurse. She said LVN E and CNA A should have never picked Resident #1 up off the floor the way they did and placed her back in bed when Resident #1 required a Hoyer lift for transfers. She said prior to moving Resident #1 she should have been assessed for pain and injury while she was still on the floor before moving her back to bed. During an interview on 4/28/2026 at 8:50am Hospice RN G said Resident #1's Family Member had sent her the video of Resident #1 fall on 4/12/26. She said she showed the video to the DON on 4/16/26. She said the video she had was from the time of Resident #1's fall to the time when CAN A and LVN E picked Resident #1 up and placed her back in the bed. She said the DON was concerned with how Resident #1 had fallen. She said she saw the resident on 4/13/26 and 4/16/26 and did not notice the discoloration or swelling. During an interview on 4/28/2026 at 10:50am CNA A Said during incontinent care she rolled Resident #1 over on her right side. She said she let go of Resident #1 to pick up supplies and Resident #1 fell off the other side of the bed. She said she panicked and tried to pick Resident #1 up and tried to put her back in bed. She said when she could not get Resident #1 back in bed she called LVN D. She said LVN D and LVN E assessed Resident #1 and then she and LVN E transferred Resident #1 back to bed by picking her up and putting her back in bed. She said that was not the proper way to do it because Resident #1 used a Hoyer lift for transfers. She said Resident #1 was not showing pain, bruising, or swelling to her leg. She said she should have put a pillow under her head and went and got the nurse and she knew that prior to the fall, but she panicked. She said she had not worked Resident #1 since the fall and was instructed not to go back in her room. Said she was aware of the video of the incident. Said no one had talked to her about the video. She said she had seen the video because LVN D had shown it to her. Said she was still currently employed at the facility and said she was supposed to work her next shift 4/29/26. She said she had been educated of the procedure for a resident fall prior to Resident #1's fall. During an interview on 4/28/2026 at 11:28am CNA K said she did not remember any discoloration or swelling to Resident #1's right leg during the 7 days from 4/12/2026 through 4/19/2026 while caring for Resident #1. She said on 4/18/26 she voiced a concern at the nurse's station, but she did not report any pain to the nurse. She said CNA L was telling her that by Resident #1 grimacing that was a sign of pain. She said she did not see Resident #1's leg discolored and was not sure how she missed that because she could clearly see it in the video. She said she did not even know Resident #1 had a fall on 4/12/2026. She said on 4/17/2026 she did not report any swelling or discoloration. She said she saw the discoloration in the video on 4/17/2026 but on that day, she did not notice it on Resident #1. She said the only thing she noticed was some bruising on Resident #1's right upper arm. She said she did not report the arm bruise either. She said she should have reported the bruise to her right upper arm to the nurse and upper management. During an interview on 4/28/2026 at 11:44am CNA L said she did not remember any swelling or discoloration to Resident #1's leg. She said after watching the videos with the Surveyor she said she knew Resident #1 was in pain on the 4/17/2026 and 4/18/2026 and told CNA K to go and report it to the nurse. She said she did not know if CNA K had reported the pain to the nurse. She said she thought that was enough to tell CNA K to let the nurse know that Resident #1 was in pain. She said looking back on it, she said she should have told the nurse herself. During an interview on 4/28/2026 at 2:23pm LVN P said she was the treatment nurse at the facility. She said the floor nurses were responsible for doing the weekly skin assessments if the resident did not have a skin issue. She said she had not assessed Resident #1's skin between 4/12/2026 and 4/19/2026. During an interview on 4/27/2026 at 3:45pm the DON said she had reviewed the video on 4/16/2026 when the Hospice RN G showed her the video. She said she did not report what she had seen on the video to the Administrator. She said the CNA had been terminated on 4/27/2026 after reviewing the video with the Surveyor. During an interview on 4/29/2026 at 10:24am LVN E said she was at the nurse's station and CNA A came and said Resident #1 was on the floor and she notified LVN D. She said she went into the room and Resident #1 was lying on the right side of the bed on the floor on her back. She said she put pillow under Resident #1's head. She said she did not see any blood or signs of pain until LVN D got there. She said then LVN D came in and took over and they got her on the bed. She said it happened very quickly and was not sure how much LVN D assessed Resident #1 while she was on the floor. She said CNA A and her lifted Resident #1 by the back, and CNA A had Resident #1 lower body, and she was lifted back on to the bed. She said she was aware that Resident #1 required a Hoyer lift for transfers. She said it was bad judgement on her part for transferring Resident #1 that way, but she was letting LVN D take the lead. Said she left the room after placing Resident #1 back on the bed. She said she just checked to make sure there was no head injury and Resident #1 was not expressing any pain. Said she did not think things were handled appropriately, she said CNA A should not have tried to pick Resident #1 up and place her back in bed by herself. She said she should have assessed Resident #1 and then gotten a Hoyer lift to place Resident #1 back in bed. During an interview on 4/29/2026 at 10:47am LVN D said on 4/12/2026 she was on break and they came and got her and CNA A told her while changing Resident #1 she rolled off the bed. She said by the time she got in there CNA A and LVN E were already there. She said they looked at Resident #1 and then placed her back in the bed. She said when she spoke with Resident #1's Family Member she told her CNA A had attempted to put Resident #1 back in bed. She said she educated CNA A not to move a resident until they were assessed by the nurse. She said Resident #1 was on the floor on the side of the bed when she entered the room. She said she went down to look at Resident #1 and said y'all let's get her up but she did look at her while she was on the floor. She said LVN E was behind her arms and CNA A was under her thighs and they picked Resident #1 up and placed her back in bed. She said she was aware that Resident #1 was supposed to be a Hoyer lift transfer. She said they should have used the Hoyer lift to transfer Resident #1 back to bed, but she could not say why they did not. She said after Resident #1 was back in bed, she looked over her and made sure she was ok. She said she did medicate Resident #1 for pain following the fall. She said at the time she did not know Resident #1 had fallen and thought it was a near fall. She said looking back at the incident she did not think her assessment was appropriate. She said she did a skin assessment on 4/15/26 and said she looked at the skin but maybe did not look at every inch of Resident #1's skin. She said the family sent her a video of CNA A attempting to pick Resident #1 back up and place her back in bed. She said the family tried to send her more videos, but she just deleted them and did not watch them. She said she did show the video to ADON C. She said the family said they sent the video to Hospice RN G. She said she did not ensure the video was sent to management. She said she did have a conversation with the DON about the video. She said the DON told her she heard about the video. The DON interrupted the interview at that time, and the nurse left the room. During a follow up interview on 4/29/2026 at 11:20am she said she should have used the Hoyer lift to get her up and she should have done a more in-depth assessment of Resident #1. She said looking back on the incident she would handle the incident differently. During an interview on 4/29/2026 at 11:57am the Administrator said moving forward her expectation that any resident that falls and they are a Hoyer transfer that the resident was to be assessed for safety and overall condition. Record review of facility policy titled Falls-Clinical Protocol dated March 2018 indicated: .2. In addition, the nurse shall assess and document/report the following: a. Vital Signs; b. Recent injury, especially fracture or head injury; c. Musculoskeletal function, observing for change in normal range of motion, weight bearing, etc.; d. change in cognition or level of consciousness; e. Neurological status; f. Pain. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happen, any observations of the events, etc. Monitoring and Follow up: 1. The staff, with the physician's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. A. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Record review of facility policy titled Acute Condition Changes-Clinical Protocol undated indicated: 1. The physician will help identify individuals with a significant risk for having acute changes of condition during their stay.3. Direct care staff, including nursing assistants, will be trained in recognizing subtle but significant changes in the resident (for example, a decrease in food intake, increased agitation, changes in skin color or condition) and how to communicate these changes to the nurse. The facility Administrator was notified on 4/27/2026 at 4:26 PM that an Immediate Jeopardy situation had been identified due to the above failures and the IJ template was given at that time. The facility's plan of removal was accepted on 4/28/2025 at 12:10 PM and included: The facility failed to assess Resident #1. All nurses to be educated by ADON on facility policy titled, Falls, regarding resident assessment post falls and prior to getting resident off the floor. Assessment will include but not limited to, complete vitals, range of motion to R/O fractures or injuries, change in LOC, pain, start neuros on all unwitnessed falls, monitor qshift X 72 hours. This to be initiated started 4/27/26 and will cont. until all nurses can verbalize proper assessment. Nurses will be educated before their next shift and all new hires and agency staff. Residents were assessed by charge nurse on 4/12/26, 4/13/26, 4/14/26, 4/15/26, 4/19/26, and 4/27/26 by charge nurse. Skin assessment was done on 4/12, 4/15, and 4/27 by charge nurse. All documented in the resident's chart. Inservice provided to nurses including completing the Skin assessment and ensuring assessments accurately reflect resident's current condition. Nurses will be educated by Treatment nurse/ designee starting on 4/28/26 and will be completed before next scheduled shift including new hires and agency staff Inservice provided to CNAs to include notifying nurses of any change in residents' skin condition. CNAs will be educated by ADON/designee starting on 4/28/26 and will be completed before next scheduled shift including new hires and agency staff Resident #1 care needs were addressed for bed mobility and incontinent care Care plan reflects dependent in bed mobility and incontinent care with 1 person assist updated on 4/27/26 by MDS nurse. Competency on facility's incontinent care, which includes supplies gathered, supplies within reach and proper bed mobility during incontinent care will be done with all CNAs. CNAs will be checked off by the ADON or designee starting 4/27/26 and will be completed before their next scheduled shift. An audit will be done on all residents' care plans to reflect proper care and information on the Kardex. This will be started on 4/27/26 by DON, MDS, ADON and continue until complete with expectation to be completed by 4/28/26. CNAs will utilize the Kardex in the POC for how to care for residents that is updated and maintained by MDS nurse or designee. CNA will be educated to utilize the Kardex by ADON starting on 4/27/26 and will be completed before next scheduled shift including new hires and agency staff. The facility failed to transfer Resident #1 back to bed with a hoyerAll CNAs and nurses to be educated on using Hoyer lift pads and machines, safe and proper techniques to transfer residents to/from bed/ chair/ floor provided by DOR or designee. Educated initiated 4/27/26 and will continue until all cnas and nurses are complete and before their next scheduled shift, including new hires and agency staff. Inservice was provided to CNA involved in incident on 4/12/26. CNA was termed on 4/27/26. Inservice with 2 nurses involved in the incident will be done by DON or designee before their next scheduled shift regarding assessment and transferring resident via hoyer lift. Since 4/1/26 to date, there have been no other falls with major injuries. An audit of falls since 4/1/26 to be completed by DON, ADON or designee on 4/28/26 to ensure proper assessment was complete. Will be completed by 4/28/26 any concerns immediately brought to medical director. On 4/17/2025, the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy by: Record review of in-service dated 4/27/2026 titled Post Fall Assessment and Fall Clinical Protocol with 17 nursing signatures. The in-services consisted of Assess resident before any resident is assisted off the floor. Assessment includes vital signs, range of motion to rule out fractures or injuries, changes in level of conscious, and pain. Start neuros on unwitnessed falls, monitor for 72 hours.Record review of in-service dated 4/27/26-4/28/26 titled Skin Assessment with 5 nurse signatures. The in-service consisted of Completing the skin assessment and insuring assessment accurately reflect resident current condition. Record review of in-service dated 4/27/26-4/28/26 titled Notifying nurses with changes with 23 nursing signatures. The in-service consisted of CNAs will notify charge nurses in residents skin condition/any changes/bruising. Record review of Resident #1's care plan reflected changes made on 4/27/26 to 1 person assist for bathing, bed mobility, meals, and 2 person assist with Hoyer transfer. Record review of 17 CNA Competency Assessments for Perineal Care dated 4/27/26-4/28/26. Record review of attestation dated 4/27/26 I attest that care plans were reviewed by DON, MDS, and ADONs. ADL care plans were updated as needed, including updating the Kardex. signed by the DON, ADON B, ADON C, and MDS. Record review of in-service dated 4/27/26-4/28/26 titled Kardex with 23 nursing staff signatures. The in-service consisted of Utilize the Kardex in the POC for how to care for residents. Record review of in-service dated 4/27/26-4/28/26 indicated 23 nursing staff had signed the in-service titled Hoyer Lift Pad and Machine. The in-service consisted of Hoyer lift pad and Machine safe and proper technique to transfer resident to/from bed/chair/floor (in the event an incident occurs). Record review of 1-1 Inservice for Hoyer lift transfers dated (add date) indicate LVN D and LVN E attended the re-education. Record review of an attestation dated 4/28/26 I attest that falls between 4/1/2026-4/27/2026 were reviewed by myself, Director of Clinical Services and ADONs for post fall assessment by the charge nurse signed by the DON, ADON B, and Adon C. Record review of in-service dated 4/27/2026 titled Bed Mobility/Repositioning/Incontinent Care Safety with 17 nursing signatures. The in-service consisted of 1. Ensure all necessary supplies are gathered, placed at bedside, within reach, prior to initiating care. 2. Ensure safe placement of resident prior to initiating care ie: middle of the bed. 3. Ensure to provide assistance per each resident's specific level of need. Ie: 2 person assist with bed mobility, Hoyer transfer. During interviews on 4/28/2025 between 12:10pm and 3:30pm the following 24 staff (MDS, RN Q, CNA R, CNA S, CNA T, CNA M, CNA U, LVN P, CNA O, CNA K, CNA L, CNA V, MA W, CNA X, LVN Y, MA Z, MA AA, CNA BB, CNA CC, LVN DD, CNA EE, RN FF, ADON B, ADON C ) were able to appropriately describe: Bed Mobility/Repositioning/Incontinent Care Safety, Hoyer lift pad and Machine safe and proper technique to transfer resident to/from bed/chair/floor, Kardex for level of care, notifying nurses with changes, Skin Assessments, and Post Fall Assessments An IJ was identified on 4/27/2026. The IJ template was provided to the facility on 4/27/2026 at 4:26pm. While the IJ was removed on 4/28/2026, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because (e.g.) all staff had not been trained on skin assessments, Kardex, Bed Mobility/Repositioning/Incontinent care, Post Fall Assessments, and Notifying Nurse with Changes.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 4 of 18 residents reviewed for infection control practices (Resident #'s 56, 4, 7, 28). 1.The facility failed to ensure the treatment nurse changed her gloves and performed hand hygiene appropriately while providing wound care to Resident #56. 2. The facility failed to ensure LVN C donned a gown before performing catheter care on Resident #4. 3.The facility failed to ensure LVN F donned a gown when she gave Peg-tube medications to Resident #7. Resident #7 was on enhancement barrier precautions. 4. The facility failed to ensure CNA E changed her gloves or sanitize her hands after performing incontinent care and applying clean brief for Resident #28. She touched a clean brief with her dirty gloves. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Findings included: 1.Record review of the undated Admission Record indicated Resident #56 was a [AGE] year-old male that admitted [DATE]. Record review of the physician's orders dated 4/1/25 indicated Resident #56 had diagnoses that included: unspecified severe protein-calorie malnutrition (a person consumes inadequate amounts of protein and calories for an extendedperiodextended period , leading to significant health problems), type 2 Diabetes Mellitus with hyperglycemia (the body does not produce enough insulin or does not use insulin effectively, leading to high blood sugar levels), heart failure (the heart does not pump as much blood as it should), and anxiety (intense, excessive, and persistent worry and fear about everyday situations.) The physician's orders indicated: 3/10/25, Wound care: Sacrum: Stage 4 pressure wound, cleanse with normal saline or wound cleanser, pat dry. Apply collagen sheet to fit wound bed, followed by dry dressing. Apply barrier cream containing zinc ointment to peri-wound (area of skin surrounding a wound) tissue. Record review of the admission MDS dated [DATE] indicated Resident #56 had clear speech, understood others and was understood by others. The MDS indicated he had a BIMS of 11 indicating moderate cognitive impairment and admitted with a stage 4 pressure ulcer (a pressure injury that extends through all layers of the skin and into underlying tissues, such as muscle, tendons, or bone.) Record review of the care plan dated 2/19/25 indicated Resident #56 had a pressure ulcer. The goal was he would have no evidence of further skin breakdown/irritation and current wounds would heal without signs or symptoms of infection . During an observation on 4/01/25 at 9:42 AM, the treatment nurse performed wound care on Resident #56. She did not change her gloves when performing wound care. With her dirty gloves she touched the collagen sheet placed on the wound and the outer dry dressing. She touched his clean brief, his blanket, and his comforter with the same gloves . She removed her gloves and without washing or sanitizing her hands adjusted the bed with the bed control. During an interview on 4/1/25 at 9:50 AM, the treatment nurse said she was supposed to change her gloves after cleaning Resident #56's wound, a dirty procedure, and before going to the clean procedure. She said she was trained to change her gloves to prevent the risk of infection. She said failing to change her gloves or wash/sanitize her hands was an infection risk to the resident and to anyone else that touched the items she had touched with her dirty gloves. Record review of a Competency Assessment, Dressings, Dry/Clean dated 9/30/24 indicated the treatment nurse was proficient in wound care. During an interview on 4/01/25 at 4:01 PM, ADON B said when doing wound care, staff should change gloves after a dirty procedure and before going to a clean procedure. She said there should be 3 glove changes during wound care. She said not changing gloves and cleaning hands could cause an infection control issue/risk for staff and residents. During an interview on 4/01/25 at 4:06 PM, ADON A said it would be an infection control risk for staff and for residents if a staff did not change gloves after performing a dirty procedure and before going to a clean procedure during wound care. She said staff were taught to change their gloves after a dirty procedure to prevent infection transmission to staff and residents. During an interview on 4/2/25 at 11:50 AM, the DON said when performing wound care the treatment nurse or staff should change their gloves after performing a dirty procedure and before going to a clean one to prevent infection to residents and staff. She said touching the bed control with hands that were not sanitized or washed was also an infection control issue. During an interview on 4/02/25 at 12:09 PM, the ADM said she expected staff to change their gloves after a dirty procedure and before going to a clean procedure to prevent infection. She said during wound care gloves should be changed several times. She said not changing gloves and washing hands could possibly cause an infection control issue to residents and staff. The ADM said staff have been trained to change their gloves when going from a dirty procedure to a clean one. 2. Record review of Resident #4's face sheet, dated 04/01/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included retention of urine (a condition where a person is unable to completely empty their bladder), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia in older adults). Record review of Resident #4's quarterly MDS assessment, dated 01/25/25, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment further indicated she had an indwelling catheter. Record review of Resident #4's Order Summary Report, dated 04/01/25, indicated she had an order for Enhanced Barrier Precautions. The start date was 04/17/24. Record review of Resident #4's undated care plan, included a focus of [Resident #4] has the potential for complications with UTI related to supra-pubic catheter secondary to retention of urine, dysfunction of bladder, and overactive bladder. The focus was initiated on 06/12/2019 and last revised on 12/05/20. Interventions included enhanced barrier precautions, initiated on 04/18/24. During an observation on 04/01/25 at 9:56 AM, LVN C provided catheter care to Resident #4. There was a EBP sign on the Resident's door. LVN C did not don (put on) a gown before providing catheter care to Resident #4. Resident #4 had a suprapubic catheter. During an interview on 04/01/25 at 10:14AM, LVN C said she should have worn a gown while providing care to Resident #4. She said it was important to follow EBP to protect residents from infection. During an interview on 04/02/25 at 12:15 PM, ADON A said LVN C should have worn a gown when providing catheter care. She said it was important to protect the resident from infection. She said it is easier for the resident with a catheter to catch an infection. During an interview on 04/02/25 at 12:26 PM, the DON said she expected LVN C to wear a gown while providing care to Resident #4. She said he risk to the resident was possible infection. She said a resident with medical devices can catch an infection easier. During an interview on 04/02/25 at 12:37 PM, the Administrator said she expected LVN C to wear a gown while providing care to Resident #4. She said the risk was a potential infection. 3.Record review of Resident #7's face sheet, dated 4/1/25, indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included muscle weakness, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), cerebrovascular disease (a medical emergency that encompasses a range of conditions affecting the brain's blood vessels and blood flow) and aphasia following unspecified cerebrovascular disease (a language disorder that affects a person's ability to communicate). Record review of Resident #7's quarterly MDS assessment, dated 2/4/25, indicated she was rarely able to make herself understood and rarely understood others. No BIMS score was conducted for Resident #7. Resident #7 required dependent assistance with ADL's. Resident #7 was always incontinent of bladder and bowel. Record review of Resident #7's care plan dated 2/21/25 indicated resident required enhancement barrier precautions related to indwelling catheter, feeding tube, and wound. Resident #7's interventions required staff to correctly put on gown and gloves and gown and gloves are used during high-contact sessions. During observation on 04/01/2025 at 7:34 A.M., LVN F checked Resident #7's residual from peg-tube and did not apply PPE; the resident was on enhanced barrier precautions. During observation on 04/01/2025 at 7:36 A.M., LVN F administered Resident #7's morning medication per peg-tube and did not apply PPE before giving medications; the resident was on enhanced barrier precautions. During an interview on 04/01/25 at 9:03 A.M., LVN F said she knew she missed up during her med pass earlier. She said Resident #7 was on enhanced barrier precautions and she forgot to apply her PPE, because she was nervous. She said staff were supposed to wear PPE for enhanced barrier precautions for residents with feeding tubes, catheters, and wounds. She said staff wear the PPE for infection control. She said if PPE was not applied during contact care staff could transfer germs and it was a risk for infections for the residents. 4.Record review of Resident #28's face sheet, dated 4/2/25, indicated an [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included muscle weakness, unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning) and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #28's quarterly MDS assessment, dated 1/17/25, indicated she was able to make herself understood and understood others. Resident #28 had a BIMS score of 10, which indicated her cognition was moderately impaired. Resident #28 required moderate assistance with toileting hygiene and showers. Resident #28 was frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #28's care plan dated 8/28/23 indicated resident have a potential for impaired skin integrity related to decreased mobility, incontinence, low albumin level and low protein intake. Intervention was to keep resident clean, dry and sheets wrinkle free. Record review of CNA D's: Clinical Proficiency-Incontinence Care sheet dated 2/17/25 indicated CNA D had met the requirements. The competency was signed by evaluator, LVN/ADON A. Record review of CNA E's: Clinical Proficiency-Incontinence Care sheet dated 2/17/25 indicated CNA E had met the requirements. The competency was signed by evaluator, RN/ADON B. During an observation on 04/01/25 at 9:47 A.M., CNA D and CNA E performed incontinent care on Resident #28. While the CNA's performed incontinent care; CNA E performed incontinent care on Resident #28 but did not remove her dirty gloves before applying a clean brief. During an interview on 04/01/25 at 12:03 P.M., CNA E said she was very nervous with surveyor watching her and she had someone helping her, but she was use to performing the incontinent care alone. She said she did not change her gloves before applying the clean brief and she felt like she did not clean Resident #28 good enough during the care. She said after performing the incontinent care she should have removed her dirty gloves, sanitized her hands and applied clean gloves before applying the clean brief. She said not changing gloves after incontinent care could put the resident at risk for infection. During an interview on 04/01/2025 at 3:24 P.M., CNA D said she saw when CNA E messed up during incontinent care with Resident #28. She said the proper way to do peri care was to wash your hands and have 3 bags. She said two things were missed, she said CNA E did not put drape over the resident and did not change her gloves or sanitize her hands, before applying the clean brief on Resident #28. She said improper hand hygiene could cause infections or an UTI. During an interview on 04/02/2025 at 9:04 A.M., CNA G said when she worked with residents on enhanced barrier precautions; she wore her PPE. She said wearing the PPE decreased the risk of any contact with infections for the staff and the residents. She said when performing incontinent care staff should sanitize their hands and apply clean gloves after performing incontinent care, before they move on to the next step. She said proper hand hygiene prevent cross contamination. During an interview on 04/02/2025 at 9:14 A.M., CNA H said if staff does not wear the correct PPE they could possibly contract what the resident has or the staff could transfer germs to the residents. She said after performing incontinent care staff should wash their hands and change gloves before a clean brief was applied. She said that would prevent cross contamination and infection. During an interview on 04/02/2025 at 9:24 A.M., LVN I said she wear her PPE with resident that were on enhancement barrier precautions to prevent cross contamination. She said after performing incontinent care staff should perform hand hygiene and change gloves, before a clean brief is applied. She said proper hand hygiene prevents infection. During an interview on 04/02/2025 at 9:41 A.M., LVN J said she wears PPE for resident on enhancement barrier precautions for protection, because the residents have some kind of open area. She said not wearing the PPE could spread bacteria for the resident and herself. She said wearing the PPE was for infection control. She said during incontinent care anytime going from dirty back to clean staff should remove dirty gloves, sanitize or wash their hands and then apply clean gloves before a clean brief was applied. During an interview on 04/02/2025 at 11:35 A.M., LVN/ADON A said the facility always encourage the staff to wear PPE for enhancement barrier precaution residents. She said the precautions are in place to prevent cross contamination. She said after peri care the aides should be sanitizing or washing and changing their gloves. She said anytime staff touched something clean they should have clean gloves on. She said improper hand hygiene could put the resident at risk for infections. During an interview on 04/02/2025 at 12:05 P.M., the DON said she expected the staff to gown up and use gloves when doing any physical activities with residents that were on enhancement barrier precautions. She said not wearing the appropriate PPE could put the residents at risk for infections. She said she excepted the staff to perform proper hand hygiene while performing care. She said CNA E should have removed her dirty gloves and performed hand hygiene before applying a clean brief. She said improper hand could cause infections with the resident. During an interview on 04/02/2025 at 12:43 P.M., the ADM said she expected the staff to wear PPE with residents that were on enhancement barrier precautions. She said if staff do not wear the proper PPE that could make the residents acceptable to infections. She said she excepted the staff to perform proper hand hygiene while performing care. She said CNA E should have removed her dirty gloves and performed hand hygiene before applying a clean brief. She said improper hand could cause infections with the resident. Record review of the facility's policy, Enhanced Barrier Precautions, dated August 2022, stated: .Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-dosing resistant organisms (MDROs) to residents . .2. EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise apply. a. Gloves and gown are applied prior to performing the high contact resident care activity (as opposed to before entering the room) . .3. Examples of high-contact resident care activities requiring the use of gown and gloves for EBPs include . .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc. ); . Record review of the facility's policy, Perineal Care, dated February 2018, stated: .The purpose of this procedure is to provide cleanliness and comfort to the resident, to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition . .9. Discard disposable items into designated containers . .10. Remove gloves and discard into designated container .11. Wash and dry your hands thoroughly . Record review of the facility's policy, Urinary Continence and Incontinence, dated August 2022, stated: For a male resident with an indwelling catheter . .1. The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence . .2. Management of incontinence will follow relevant clinical guidelines . .3. The physician and staff will provide appropriate services and treatment to help residents restore or improve bladder function and prevent urinary tract infections to the extent possible . Record review of the facility's policy, Dressing, Dry/Clean, dated September 2013, stated: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings . Steps in the Procedure .1. Clean bedside stand. Establish a clean field. .2. Place the clean equipment on the clean field. Arrange the supplies so they can be easily reached. .3. Tape a biohazard or plastic bag on the bedside stand or use a waste basket below clean field. .4. Position resident and adjust clothing to provide access to affected area. .5. Wash and dry your hands thoroughly. .6. Put on clean gloves. Loosen tape and remove soiled dressing. .7. Pull glove over dressing and discard into plastic or biohazard bag. .8. Wash and dry your hands thoroughly. .9. Open dry, clean dressing(s} by pulling corners of the exterior wrapping outward, touching only the exterior surface. .10. Label tape or dressing with date, time and initials. Place on clean field. .11. Using clean technique, open other products (i.e., prescribed dressing; dry, clean gauze). .12. Wash and dry your hands thoroughly. .13. Put on clean gloves. .14. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing progress and wound stage. .15. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. Clean from the least contaminated area to the most contaminated area (usually, from the center outward). .16. Use dry gauze to pat the wound dry. .17. Apply the ordered dressing and secure with tape or bordered dressing per order. (Note: Use non- allergenic tape as indicated.) Label with date and initials to top of dressing. .18. Discard disposable items into the designated container. .19. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. .20. Reposition the bed covers. Make the resident comfortable. .21. Place the call light within easy reach of the resident. .22. Clean the bedside stand. .23. Wash and dry your hands thoroughly. .24. If the resident desires, return the door and curtains to the open position and if visitors are waiting, tell them that they may now enter the room . Record review of the facility's policy, Wound Care, dated October 2010, stated: The purpose of this procedure is to provide guidelines for the care of wounds to promote healing . .15. Remove the disposable cloth next to the resident and discard into the designated container . .16. Discard disposable items into the designed container. Discard all soiled laundry, linen, towels, and wash cloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly . Record review of the facility's policy, Infection Control Guidelines for All Nursing Procedures, dated August 2012, stated: To provide guidelines infection control while caring for residents . .2. Prevention of the transmission of multi-drug resistant organism . .3. a. Before and after direct contact with residents . .b. When hands are visibly dirty or soiled with blood or other body fluids . .c. After contact with blood, body fluids, secretions, mucous membranes, or nonintact skin . 46929 48958

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 20 residents (Resident #48) reviewed for adequate supervision. The facility failed to keep prohibited items, isopropyl rubbing alcohol, out of Resident #48's room. This failure could place residents at risk for injury, harm, and impairment or death. Findings included: Record review of Resident #48's Admission Record indicated she was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included Amyotrophic Lateral Sclerosis (progressive and fatal neurodegenerative disease that affects the motor neurons in the brain and spinal cord), Chronic Obtrusive Pulmonary Disease (a group of lung diseases that cause progressive airflow obstruction and breathing difficulties), Type 2 Diabetes (a chronic condition where the body does not use insulin effectively or does not produce enough insulin to regulate blood sugar levels). Record review of Resident #48's MDS dated [DATE] revealed that the resident's BIMS score was a 10 indicating mild cognitive impairment. The MDS also revealed, Resident #48, required maximal assistance for all ADLs. Record review of Resident #48's Care Plan revealed a problem initiation on 10/21/2022 for a Moderately impaired vision - not able to read large or small print but can identify objects: nuclear cataracts, cortical senile cataract, myopia with astigmatism and presbyopia of both eyes (you have a combination of age-related vision changes, including clouding of the lens, nearsightedness, blurry vision at all distances, and difficulty focusing on near objects). During an observation and interview on 3/31/25 at 9:26 a.m., Resident #48 had a bottle of isopropyl alcohol on his bedside table. He said that he has always had that bottle on his bedside table and uses it to clean up. During an observation on 4/1/25 at 3:04 p.m. Resident #48 had a bottle of isopropyl rubbing alcohol on his bedside table. During an interview on 4/1/25 at 3:08 p.m. LVN C said residents were not allowed to have any over the counter medications or rubbing alcohol in their rooms . She said there was a risk that a resident could swallow the rubbing alcohol. She said that they would need to call poison control if a resident swallowed rubbing alcohol. During an interview on 4/2/25 at 12:25 p.m., the Director of Nurses said that residents were not allowed to have prohibited medications or medical products in their rooms. She said that rubbing alcohol was a prohibited item and residents could not keep that unsecured in their rooms. She said there was a risk that a resident could drink the alcohol and call poison control. She said it was the responsibility of all staff to ensure prohibited items are not in resident rooms. During an interview on 4/2/25 at 12:28 p.m., the Administrator said that residents were not allowed to have prohibited medical related items in their rooms. She said that rubbing alcohol was a prohibited item and residents could not keep it unsecured in their rooms. She said there was a risk that a resident could be harmed She said it was the responsibility of all staff. Record review of a facility policy dated 2001 entitled Hazardous Areas, Devices and Equipment, All hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible As part of the facility's overall safety and accident prevention program, hazardous areas and objects in the resident environment will be identified and addressed by the safety committee A hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to the following: Access to toxic chemicals

Based on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #4) reviewed for appropriate treatment and services to prevent urinary tract infections (an infection in any part of the urinary system, the kidneys, bladder, or urethra (is a hollow tube that lets urine leave your body)). The facility failed to ensure Resident #4's indwelling suprapubic catheter (drains urine from your bladder into a bag outside your body) had a catheter securement device to anchor the catheter to her leg. This failure could place residents at risk for urinary tract infections. Findings included: Record review of Resident #4's face sheet, dated 04/01/25, indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Her diagnoses included retention of urine (a condition where a person is unable to completely empty their bladder), and Alzheimer's disease (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia in older adults). Record review of Resident #4's quarterly MDS assessment, dated 01/25/25, indicated she had a BIMS score of 11, which indicated moderate cognitive impairment. The MDS assessment further indicated she had an indwelling catheter and an ostomy (a surgically created opening, or stoma, in the abdominal wall that allows waste (stool or urine) to exit the body when the normal digestive or urinary pathways are damaged or removed). Record review of Resident #4's Order Summary Report, dated 04/01/25, indicated she had an order for Suprapubic catheter privacy bag and securement device. Ensure placement every shift. The start date was 02/04/25. Record review of Resident #4's undated care plan, included a focus of [Resident #4] has the potential for complications with UTI related t osupra-pubic catheter secondary to retention of urine, dysfunction of bladder, and overactive bladder. The focus was initiated on 06/12/2019 and last revised on 12/05/20. Interventions included monitor placement of catheter leg strap every shift, initiated on 04/24/24. During an observation on 04/01/25 at 9:56 AM, LVN C provided catheter care to Resident #4. Resident #4 had a suprapubic catheter. Prior to the care Resident #4 did not have a catheter securement device in place. During an interview on 04/01/25 at 10:00AM. LVN C said Resident #4 should always have a catheter securement device in place. She said she was not sure why the resident did not have a catheter securement device in place. During an interview on 04/01/25 at 10:43AM, LVN C said Resident #4 was supposed to have a catheter securement device in place. She said it was important to have a catheter securement device in place because it avoids the catheter pulling and helps keep it in place. She said the nurse was responsible for ensuring the device was in place. She said it was the responsibility of the nurse to check for the device each shift. During an interview on 04/02/25 at 12:15 PM, ADON A said she expected Resident #4 to have a catheter anchor in place. She said it was important to keep the anchor in place so the catheter did not pull out. She said the risk to the resident was that without the catheter, it could pull and cause pain, an injury, or even an infection. During an interview on 04/02/25 at 12:26 PM, the DON said Resident #4 should have had a catheter securement device in place. She said the nurse should verify the anchor was in place each shift. She said it was important for the anchor to be in place to prevent the catheter from being pulled out. She said the risk was infection and pain. During an interview on 04/02/25 at 12:37 PM, the Administrator said she expected the resident to have a catheter securement device in place. She said the catheter could have been pulled out. She said the risk to the resident was pain and a possible infection. Record review of the facility's undated policy, Catheter Care, Urinary, stated: .Ensure that the catheter remains secured with a securement device to reduce friction and movement at the insertion site .

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored and disposed of properly, for 1 of 6 residents (Resident #56) reviewed for medication storage. 1.The facility failed to ensure Resident #56's humlin ,d+[DATE] insulin was properly stored in the refrigerator. 2. The facility failed to ensure Resident #56's humlin ,d+[DATE] insulin with an expired date was disposed of. This failure could place residents at risk of not receiving the therapeutic benefit of medications and adverse reactions to medications due to improper storage. Findings included: 1.Record review of Resident #56's face sheet, dated [DATE], indicated a [AGE] year-old male who initially admitted to the facility on [DATE] with diagnoses which included type 2 diabetes mellitus with hyperglycemia( a condition where the body does not use insulin effectively, leading to high blood sugar levels), muscle weakness, unspecified severe protein calorie malnutrition (a condition where a person does not consume enough calories and protein to meet their nutritional needs) and chronic kidney disease (longstanding disease of the kidneys leading to renal failure). Record review of Resident #56's quarterly MDS assessment, dated [DATE], indicated he was able to make himself understood and understood others. Resident #56 had a BIMS score of 11, which indicated her cognition was moderately impaired. Resident #56 required dependent assistance with ADL's . Resident #56 was always incontinent of bladder and bowel. Record review of Resident #56's physician orders, dated [DATE], indicated humlin ,d+[DATE] subcutaneous suspension (,d+[DATE]) 100unit/ milliliter (Insulin NPH Isophane and Reg (Human). Inject 5 units subcutaneously at bedtime for diabetes mellitus, hold for blood sugar less than 100. Record review of Resident #56's care plan dated [DATE] indicated resident was at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/hypoglycemia, renal failure, cognitive/ physical impairment/ skin desensitized to pain or pressure, slow healing process related diagnosis of Diabetes Mellitus. Interventions were for staff to observe resident for signs of hyperglycemia (blood glucose >140mg/di; increase thirst, increase urination; increase appetite followed by lack of appetite; nausea, vomiting) and observe for signs of hypoglycemia (blood glucose<60mg/deciliter; sweating; cold; clammy skin; numbness of fingers, toes, mouth; rapid heartbeat; nervousness; tremors, faintness, dizziness). During an observation on [DATE] at 9:30 A.M., with LVN K in back hall medication room. There were three bottles of humlin ,d+[DATE] insulin with Resident #56's information on it in a cabinet. Two of the bottles were not opened but one bottle had an expired date [DATE] on it which indicated been used. During an interview on [DATE] at 10:02 A.M., LVN I said the insulin should have been stored in the refrigerator until it was opened. She said after an insulin was opened it was good for 20 days. She said she believed that the insulin found in the cabinet and not refrigerated came from Resident #56's home. She said the facility used the insulin until the resident's meds came from their pharmacy. She said the insulin should have been disposed of or sent back home with the family if the facility was not going to use it. She said since the insulin was improperly stored if it was used for Resident #56 it would not have been effective. During an interview on [DATE] at 10:10 A.M., LVN K said insulin should be stored in the refrigerator if it had not been used. She said if insulin was not stored properly the effectiveness of the insulin would be at risk. She said the resident would not get the desired effect, which would be to decrease the blood sugar level. During an interview on [DATE] at 11:35 A.M., LVN/ADON A said the insulin should have never been stored in the cabinets. She said unused insulin should be stored in the refrigerator. She said the nurses were responsible for the storage of the medications. She said improper storage of insulin would make the medication ineffective for the resident. During an interview on [DATE] at 12:05 P.M., the DON said the insulin was a medication Resident #56 brought from home. She said the staff should have sent the medication back home with the family or destroyed it. She said an insulin improperly stored would not be effective for a resident. She said all unused insulin should be stored in the refrigerator until use. She said the facility has started an in-service over medication storage. During an interview on [DATE] at 12:43 P.M., the ADM said she expected staff to properly store medications. She said the insulin should have been stored in the refrigerator or sent home with the family. She said improper storage of insulin would not be effective for the desired use of insulin. Record review of the facility's policy, Medication Labeling and Storage, undated, stated: The facility stores all medications and biologicals in locked compartments under proper temperatures, humidity, and light controls. Only authorized personnel have access to keys. .3. If a medication has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items . .6. Medications requiring refrigeration are stored in a refrigerator located in the medication room at the nurse's station or other secured location. Medications are stored separately from food and are labeled accordingly .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen (Main Kitchen), in that: On [DATE] the facility failed to ensure food was discarded by the expiration date. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness. The findings included: During an observation, in the dry storage area inside of the kitchen, on [DATE] at 09:00 a.m., revealed one box of Swiss Miss hot chocolate mix containing twenty 0.73 ounce packets with expiration date of [DATE], three 13 ounces packets of Morrisons brown gravy mix with expiration date of [DATE]. During an observation, of emergency food supply, on [DATE] at 09:25 a.m., revealed six 8lb cans of Carriage House grape jelly with the expiration date of [DATE], 2 cases of twenty-four 4 ounce cups of Sysco diced pears with the expiration date of [DATE], one case of sixteen 14 ounce packets of Folgers coffee with the expiration date of [DATE], 4 cases of ninety-six 1.25 ounce packs of Malt O'Meal raisin bran cereal with the expiration date of [DATE], 2 cases of ninety-six 1.25 ounce packs of Malt O'Meal crispy rice cereal with the expiration date of [DATE], 1 case of ninety-six 1.25 ounce packs of Malt O'Meal crispy corn flakes with the expiration date of [DATE], 140 cups Snack Pack vanilla pudding 3.25 ounce cups with the expiration date of [DATE]. During an observation and interview on [DATE] at 09:25 a.m. the DM confirmed, by observations, that items in the dry storage area, and emergency food supply were not discarded by the expiration dates. During an interview on [DATE] at 02:18 p.m., the DM said she had worked at the facility for about [AGE] years. She said it was her responsibility to check the expiration dates on all food in the kitchen. She said the last time she checked the food in the pantry in the kitchen was [DATE]. She said she was supposed to check the food expiration dates on the day's groceries were delivered. She said she last checked the emergency food supply about ,d+[DATE] weeks ago but did not get to finish. She said consuming expired foods could put the residents at risk of food borne illnesses. She said the facility policy was all expired food was to be discarded by the expiration dates. During an interview on [DATE] at 03:00 p.m. the Administrator said he had worked at the facility for about 1 year. He said his expectations was for all expired food to be thrown away or sent back to the food company. The Administrator said, I've eaten expired food before, and it did not hurt me but maybe it could cause food borne illnesses. Record review of facility policy titled Dry Storage and Supplies dated 2012, revealed All facility storage areas will be maintained in an orderly manner that preserves the condition of food and supplies. We will ensure storage areas are clean, organized, dry and protected from vermin, and insects. The facility policy did not address expiration dates. Record review of the facility policy titled Use by Date Guide undated revealed: The following guide should be used to determine a use by date when labeling opened or unopened food that must be used within a certain timeframe. An exception to this would be if the manufacturer use by date comes before the date determined using the labeling guide.

Based on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Three of six gas stove burners (front middle, right front, and right back) did not light automatically on 03/18/2024, when the knob was turned, the pilot light on the burners would not stay lit and both burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food. Findings included: During an observation on 03/18/24 at 9:00 AM, the gas stove had six burners and three burners located in the front middle, right front, and right back had excess carbon buildup. The burners would not light automatically and the pilot light would not stay lit. During an interview on 03/18/24 at 10:30 AM, the Cook stated she notified the Maintenance Director on 03/11/24 that the burners were not working. She said the Maintenance Director came and worked on the stove and the burners worked that day but the next day they were not working again. She said she notified the Maintenance Director again the next day and he came and tested the burners, but he had not been back since and burners continued to not work. She said the dietary manager was aware the burners did not work. She stated that the burners not working correctly could be a fire hazard. During an interview on 03/19/24 at 10:28 AM the Maintenance Director said the ovens were deep cleaned this past weekend 3/15/24-3/17/24. He said he was called by the kitchen and told that a few of the stove burners were not working properly. He said he had checked on it first thing Monday morning 3/11/24 and noticed that the pilot light has a flame but took forever to light. He said the stove had a 1-year warranty, so he was working on getting someone to come out and repair the burners that are not working. He said even if it was not covered by warranty, he would still have the burners repaired . He said he was going to call and check on the status of the repair person coming out. During an interview on 03/19/24 at 02:18 PM the DM stated that she and the other kitchen staff were responsible for maintaining the stove and keeping it clean. She stated if the burners were not working, or the carbon build up was excessive then she would tell the Maintenance Director. She stated she was aware of the burners not working and had notified the Maintenance Director. She said the Maintenance Director told her the burners may be stopped up. She said the Maintenance Director told her on 3/19/24 that he was going to call the manufacturer to check on the warranty. She stated if the stove was not working correctly, it could be a fire hazard. During an interview on 03/20/24 at 3:00 PM the administrator stated it is news to me the stove in the kitchen was not in working order. The Administrator said that a deep clean was done on Friday 3/15/24 and no one mentioned to him there was a problem with the stove, or he would have taken care of it. The Administrator said the stove may still be under warranty. He said the Maintenance Director had asked him on 3/18/24 who the stove was purchased from. He said there was an open service call on the stove. The Administrator said the stove not working properly would not interfere with resident meals. On 3/18/24 the Surveyor requested a facility policy regarding essential equipment, and none was provided by the time of exit.

Based on observation, interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported to Texas Health and Human Services Commission immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 5 (Resident #8) residents reviewed for abuse and neglect. The facility did not report an allegation of abuse that occurred between 3/8/24-3/10/24 when Resident #8 reported to LVN A that CNA B had been rough while providing care and had caused a bruise on her right thigh. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings included: Record review of a facility face sheet dated 3/19/24 for Resident #8 indicated that she was a [AGE] year-old female that admitted to the facility on [DATE] with diagnosis of chronic obstructive pulmonary disease (causes airflow blockage and breathing related problems), schizophrenia (affects a person's ability to think, feel, and behave clearly), and muscle weakness. Record review of a Quarterly MDS assessment dated [DATE] for Resident #8 indicated that he had a BIMS score of 11 indicating that she had a mildly impaired cognitive deficit. Record review of a comprehensive care plan for Resident #8 revised on 11/14/23 indicated that she was PASRR positive due to a severe mental illness. Resident #8 refused all PASRR services and had signed refusal of PASRR MI specialized services form 1041. During an interview on 3/18/24 at 10:42 AM, Resident #8 said on Thursday 3/14/24 or sometime last week (could not remember exact day) CNA B had come into her room to put on her nighttime brief, and CNA B jerked the right side of the brief up causing a tear in the skin at the crease of her thigh and groin area. Resident #8 said she yelled out that it hurt, and CNA B jerked up the right side of the brief again causing a bruise to her right upper thigh. Resident #8 said she reported the incident to LVN A the night it happened. Resident #8 said LVN A went and filled out a report about the incident and brought it back for her to sign. Resident #8 said after she signed the report LVN A told her she was going to place it under the door of [NAME] (no known staff by that name). Resident #8 said after she reported the incident to LVN A she had not heard anything else about the incident. During an interview by phone on 3/18/24 at 6:52 PM, LVN A said Resident #8 did report to her that CNA B had pulled Resident #8's brief up to rough while putting on her nighttime brief. LVN A said she told Resident #8 to talk to the Administrator. LVN A said she did not fill out any kind of report or have Resident #8 sign anything. LVN A said she did not report the incident to the Administrator or DON because Resident #8 said she was going to report the incident to administration on Monday. LVN A said she did not feel like CNA B had intentionally hurt Resident #8 and felt like Resident #8 had a personal issue with CNA B. LVN A said she did not remember what specific day the incident took place but thought it happened over the weekend of 3/8/24-3/10/24. LVN A said she had been trained on reporting abuse and neglect but did not think Resident #8 had been abused so she did not report it. LVN A said the facility policy was to report all allegations of abuse to the Administrator. On 03/19/24 8:41 AM, Attempted phone interview with CNA B, she did not answer or return call by the time of exit. During an interview on 3/19/24 at 9:30 AM Resident #8 said the Administrator had come to her room earlier that morning and talked to her regarding the incident with CNA B. Resident #8 said she did not get to tell the Administrator the whole story of what happened during the incident because the Administrator did all the talking and would not let her finish telling him what had happened. During an observation and interview on 03/19/24 at 09:33 AM with the ADON C present observed Resident #8's groin area with red raw irritated with no obvious skin tear in the crease of the groin, no bruises observed to the right thigh area. Resident #8 said the bruises are healing up now because it happened last week. While skin was being observed Resident #8 told ADON C that CNA B had come in to put on her nighttime brief and jerked the right side of her brief up and caused a tear in the crease of her right leg. Resident #8 said she yelled out ouch that hurt and CNA B jerked the brief up again causing a bruise to her right leg. During an interview on 3/19/24 at 9:37 AM, the ADON C said she worked at the facility for about 1 year. She said LVN A called her on 3/18/24 around 7:30pm after speaking to the surveyor and asked her if she was going to lose her job because she did not report that Resident #8 had said CNA B was being rough with her. The ADON C said she returned to the facility and the ADON C and LVN A went to Resident #8's room and Resident #8 described her interaction with CNA B as rough. Stating that CNA B pulled her brief up too tight causing bruising. The ADON C said Resident #8 also stated that she had told someone about the situation a week ago on a Monday. The ADON C said she felt like the incident was more of a personality conflict between Resident #8 and CNA B. The ADON C said CNA B normally dotes on Resident #8 and she thought CNA B told Resident #8 that she could be more independent and do some of her own tasks and it would make her stronger and Resident #8 got mad at CNA B for that. The ADON C said CNA B was on vacation out of state and had not spoken with her. The ADON C said she started staff education on: Skin Assessments/Reporting Skin Changes, Safe Handling, Skin Integrity on 3/18/24. The ADON C said she had not started abuse education training. During an interview on 3/19/24 at 9:58 AM the Administrator said he was notified that a surveyor was asking questions about Resident #8 and a possible allegation of abuse at approximately 9:00pm on 3/18/24. He said he did not report the incident to HHSC because he did not feel like the incident was abuse. The Administrator said he and the SW spoke with Resident #8 and she told him CNA B was hateful and talking to her in a way she did not like and did not like CNA B's approach. The Administrator said Resident #8 told him CNA B put a brief on her and that she had a bruise on her leg but did not say what the bruise was from. He said he did not speak with LVN A that the complaint was originally reported to because the DON was handling the investigation on 3/18/24 due to him being in the ER with his 1 1/2 year old child. He said he had not reported the incident as of 3/19/24 at 9:58am because Resident #8 did not make the allegation of abuse to him. During an interview on 3/19/24 at 10:30 AM, the SW she said she went to speak with Resident #8 with the administrator the morning of 3/19/24. She said Resident #8 said CNA B has an attitude and said to her what do you want but did not say anything about the CNA B being physical. The SW said Resident #8 said CNA B told Resident #8 to not push her call light. The SW said Resident #8 did not mention anything about the brief or bruise. The SW said she had not received any complaints about CNA B before. During an interview on 3/20/24 at 9:16 AM, the DON said she had worked at the facility for about 1 year. The DON said she received a text message from the ADON C and was notified of the alleged abuse by Resident #8 on 3/18/24 at 7:40pm and said she notified the administrator on 3/18/24 at 7:55pm. The DON said she was notified that Resident #8 complained to a the surveyor that CNA B was too rough putting a brief on her and had bruised her. The DON said the ADON C and LVN A did a skin assessment on 3/18/24 and did not find a bruise. She said the ADON C started in-servicing staff on Skin Assessments/Reporting Skin Changes, Safe Handling, Skin Integrity. The DON said she identified who the CNA was and made sure she was not working. The DON said the ADON C made sure Resident #8 was safe. The DON said she had not spoken with CNA B due to her being out of state on vacation. The DON said whether or not the abuse occurred, CNA B will not care for Resident #8 anymore. The DON said on 3/18/24 was the first time she had heard of the incident and LVN A had not reported the incident to her. The DON said that LVN A felt like Resident #8 was a constant complainer and took it as being another issue verses something she should report. The DON said the investigation was still pending and the SW had been doing safe surveys. The DON said her expectation was for staff to report all allegations of abuse to the administrator or if it was reported to a nurse manager, they would get that information to the administrator. The DON said the potential negative outcome for staff not reporting alleged abuse was the potential for further abuse to the resident. On 03/20/24 11:28 AM Attempted phone interview with CNA B, she did not answer or return call by the time of exit. During an interview on 3/20/24 at 1:08 PM the Administrator said his expectation was that staff were to report all allegations of abuse to him or their supervisor immediately. The Administrator said the resident could potentially continue to be subjected to abuse if staff did not follow the facility abuse policy. Record Review of the ADON C statement dated 3/18/24. The statement revealed: On the evening of March 18, 2024, I returned to the facility after receiving a call from the charge nurse, LVN A, in regard to Resident #8. After arriving I had LVN A to go with me to resident room. I was able to visit with Resident #8 in regard to her concern with night CNA B. Resident #8 described her interaction with CNA B as Rough. Stating that CNA B pulled her brief up too tight causing bruising . Record review of a facility incident log for March 2024 indicated that no incident report was filed for an incident regarding Resident #8. Review of website for state complaints and incidents on 3/18/24 revealed there was no self-report to HHSC for incident on Resident #8 from facility. Record review of in-service dated 1/2/24 titled Abuse/Neglect Reporting/Identifying revealed CNA had been educated prior to the incident. Record review of in-service dated 2/29/24 titled Abuse/Neglect Reporting/Identifying revealed LVN had been educated prior to the incident. Review of website for state complaints and incidents on 3/19/24 revealed the incident with Resident #8 had been reported to HHSC on 3/19/24 at 10:39am. Record review of facility titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating with a revised date of September 2022 revealed: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The Administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility;.

Based on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 12 residents reviewed for ADLs (Residents #48.) The facility did not clean or trim Resident #48's fingernails on 03/18/2023, 03/19/2024 and 03/20/2024. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. The findings included: Review of Resident #48's electronic face sheet dated 09/22/22 revealed a [AGE] year old male who was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure (shortness of breath or feeling like you can't get enough air, extreme tiredness, an inability to exercise as you did before, and sleepiness), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Cardiac Pacemaker (a small, battery-powered device that prevents the heart from beating too slowly). Record review of Resident #48's annual MDS dated [DATE] revealed a BIMS with a score of 09, which indicated Resident #48 had moderately impaired cognition. The MDS also revealed, Resident #48, required total assistance with ADLs. Record review of Resident #48's care plan dated 1/24/24 revealed a problem initiated on 4/14/20. Resident #48 requires assistance with ADLs including personal hygiene. Care plan reflected that Resident # 48 will maintain a sense of dignity by being clean, odor free, and well groomed. During an interview and observation on 3/18/24 at 9:51 a.m., Resident #48 said he wanted his fingernails cut. He said he did not know when his nails were cut last. He said he was unable to cut his own nails. He said a staff had cut them in the past. Resident #48's nails were long and there was a black unknown substance under his nails. During an observation on 3/19/24 at 3:20 p.m., Resident #48 nails were long and there was a black unknown substance under his nails. During an observation on 3/20/24 at 8:55 a.m., Resident #48 nails were long and there was a black unknown substance under his nails. During an interview on 03/20/24 at 9:20 a.m., with the DON she said residents could be placed at risk for infection if their fingernails were not cut and maintained. She said that it was the responsibility of the CNAs to ensure that residents who were dependent for ADLs were cared for and their nails were kept cut and clean. Review of the facility policy and procedure titles Activities of Daily Living (ADL), Supporting revised March 2018 revealed that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs) .Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 2 of 12 residents (Resident #35 and Resident #37) reviewed for respiratory care. The facility failed to change the filters on oxygen concentrator machines that were in use for Resident #35 and Resident #37. These failures could place residents at risk for of respiratory infections. Findings included: 1.Record review of an undated face sheet revealed Resident #35 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Autonomic Neuropathy (the damage to nerves that control your internal organs), Muscle Weakness (commonly due to lack of exercise, ageing, muscle injury or pregnancy), Anxiety Disorder (persistent and excessive worry that interferes with daily activities). Record review of the MDS dated [DATE] revealed Resident #35 had a BIMS of 13, which indicated she was cognitively intact. MDS reflects Resident #35 received oxygen therapy. MDS reflected resident #35 required assistance with ADLs. Record review of the Resident # 35's care plan dated 2/17/24 revealed Resident #35 was on oxygen therapy. Care plan revealed that Resident #35 will have no signs or symptoms of poor oxygen absorption. During an observation and interview on 3/18/24 at 9:37 a.m., Resident # 35 said she used the oxygen concentrator every day. She said she did not know if the staff cleaned the machine or not. The concentrator was observed and the oxygen filter on Resident # 35's oxygen concentrator had a dirty filter. The filter had white and grey substances covering the filter. During an observation on 3/20/24 at 9:15 a.m., Resident #35's air concentrator filter was dirty. The filter had unknown white and gray particles covering the air filter. 2. Record review of an undated face sheet revealed Resident #37 was an [AGE] year-old, female, and admitted on [DATE] with diagnoses including Chronic Obtrusive Pulmonary Disease (a common lung disease causing restricted airflow and breathing problems), Acute Respiratory Failure with Hypoxia (a condition where you don't have enough oxygen in the tissues in your body), Lack of Coordination (Impaired balance or coordination, can be due to damage to brain, nerves, or muscles). Record review of the MDS dated [DATE] revealed Resident #37 had a BIMS of 11, which indicated she had mildly impaired cognition. MDS reflected Resident #37 received oxygen therapy. MDS reflected Resident #37 required assistance with ADLs. Record review of the Resident # 37's care plan dated 1/24/24 revealed Resident #37 was on oxygen therapy related to Chronic Obtrusive Pulmonary Disease. The care plan revealed that Resident #37 will have no signs or symptoms of poor oxygen absorption. During an observation and interview on 3/18/24 at 9:32 a.m., Resident #37 said she was not sure if anyone cleaned the air filter on the oxygen concentrator she used. She said she used the oxygen concentrator every day. It was observed that the oxygen concentrator machine had a dirty filter. The filter had unknown white and gray particles covering the air filter. During an observation on 3/20/24 at 9:13 a.m., Resident #37's air concentrator filter was dirty. The filter had unknown white and gray particles covering the air filter. During an interview on 03/20/24 at 9:20 a.m., the DON said nursing staff were responsible to ensure all oxygen tubing and filters were changed on the oxygen concentrators. She said there could be a risk for infection or the equipment malfunctioning when the oxygen concentrator did not have a clean filter. During an interview on 3/20/24 at 1:08 p.m., the ADM said nursing staff were responsible to clean the filters on oxygen concentrators. He said he could not state the risks of oxygen concentrators with dirty filters as he was not a medical professional. A record review of an oxygen concentrator policy was not completed as the facility was unable to provide a policy that addresses oxygen concentrators prior to exit.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental, and psychosocial needs for 1 of 5 resident's reviewed for care plans. (Resident #1) The facility failed to ensure Resident #1's general surgeon (medical doctor) was informed of her care, as a follow-up appointment was missed and not rescheduled. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: Record review of Resident #1's face sheet, printed on 02/29/24, indicated she was a [AGE] year old female, originally admitted to the facility on [DATE]. Her diagnoses included perforation of intestine (a hole in the intestine that can cause stool to leak into the abdomen), chronic kidney disease stage 4 (severe loss of kidney function), down syndrome (a genetic condition that causes mild to significant physical and developmental problems), and type 2 diabetes mellitus (a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #1's admission MDS assessment, dated 01/09/24, indicated she had a BIMS score of 10, which indicated moderate cognitive impairment. She was usually able to make herself understood and usually able to understand others. She did not exhibit behaviors of rejection of care or wandering. She had a surgical wound that required surgical wound care. Record review of Resident #1's care plan initiated on 01/23/24, and last revised on 02/28/24, indicated a focus of has alteration in skin integrity as evidenced by surgical wound to abdomen. The interventions included: * Assess for possible reasons for skin concerns, report findings to MD * Keep MD and RP informed of resident's progress * Monitor area for increased breakdown, signs/symptoms of infection, report to MD Record review of Resident #1's hospital after visit summary, dated 01/22/24, indicated she had a post-op appointment scheduled on January 25th, 2024 with the general surgeon that performed her abdominal surgery during the hospitalization . Record review of Resident #1's hospital after visit summary, dated 01/30/24, indicated call [general surgeon], MD in 1 week(s). the summary further indicated Please notify [general surgeon] of any issues or concerns with the wound. During an interview on 02/29/24 at 1:00PM, the DON said as far as she was aware Resident #1 did not go to a follow up appointment with her general surgeon. She said Resident #1 missed her 3 week follow-up appointment with the general surgeon because it was not on her hospital discharge orders from 01/30/24. She said since the appointment was not on her new discharge orders she did not expect for the resident to go to a follow-up with the abdominal surgery doctor. She said the wound care doctor was her first line for wounds and she would not expect to send Resident #1 to the general surgeon unless there was a significant issue. She said even though the surgical wound was open and being treated by the wound care doctor she did not reach out to the surgeon to notify him or schedule a follow up. During an interview on 02/29/24 at 1:35PM, LVN C said she was responsible for scheduling residents' outside appointments. She said Resident #1 had a follow-up scheduled with the general surgery office for January 25th, 2024 and the resident did not go to that appointment because she returned to the hospital on that day. She said the resident's family called and cancelled the appointment because the resident was in the hospital. She said rescheduling the appointment was missed. She said she thought it was important for Resident #1 to make it to her surgical follow up appointments. She said by missing the appointments Resident #1's condition could have worsened and her overall status could have worsened. During an interview on 02/29/24 at 1:44PM, Certified Medical Assistant D said she worked at the general surgeon's office. She said the office expects the patients to make it to their follow up appointments because the doctor likes to follow up on surgical wounds. She said she expected the facility to reach out and let them know of the reason for missing the appointment and then reschedule when possible. During an interview on 02/29/24 at 2:00PM, the DON provided the hospital after visit summary dated 01/30/24. She said the after visit summary from 1/30/24 indicated call [general surgeon], MD in 1 week(s). She said those statements she sees as telling the facility to take care of the specific problem. She said sometimes the after visit summaries say call primary care doctor and they have a primary care doctor in house that they would use instead of an outside doctor. She said even though the discharge paperwork said contact the general surgery MD she expected her staff to not contact the surgeon because the wound care doctor was taking care of the wound. She said the facility did not have a policy that addresses the making of appointments and making sure that follow-up appointments are not missed. She said we are not regulated to have a policy on that so we do not have one. During an interview on 02/29/24 at 2:18PM, Practice Manager E said she was the practice manager at the general surgeon's office. She said the general surgeon was unavailable for comment at that time. She said she expected the facility to keep a follow up appointments with the surgeon and reschedule if needed. During an interview on 02/29/24 at 4:18PM, LVN F said he thought residents with follow up appointments should go to the appointment. He said if an appointment was missed then he would contact the surgeon's office and ask if they still want the resident to have the appointment or not. He said he would also contact the primary doctor and ensure everyone was on the same page. During an interview on 02/29/24 at 4:20PM, ADON B said someone should have followed up with Resident #1's surgeon to see if he still wanted her to come to the appointment after her hospitalization . She said the risk to Resident #1 was an adverse situation such as an infected wound and prolonged healing. During an interview on 02/29/24 at 4:24PM, ADON A said she expected someone to follow up with the surgeon after Resident #1 returned to the facility from her hospitalization to see if the surgeon still wanted the follow-up appointment or not. She said the admitting nurse was responsible for making the appointment. She said if the admitting nurse was unable to make the appointment, then the next day shift nurse was responsible for ensuring the appointment was made. She said the risk to the resident not having a follow up appointment with the surgeon was a possible wound infection. During an interview on 02/29/24 at 4:29PM, the Administrator said he expected the staff to at least call the surgeon's office to see if they still wanted a follow-up appointment. He said the risk to the resident because she did not have a follow up appointment was a possible infection.

Based on observation interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 residents reviewed for grievances. (Resident #1) The facility Administrator and DON failed to document, resolve, and follow up on grievances related to quality of care on behalf of Resident #1 on 01/26/2024 and 02/09/2024. These failures could place residents at risk for grievances not being addressed or resolved promptly. Findings included: Record review of Resident #1's face sheet dated 2/16/24 indicated Resident #1 was a [AGE] year-old female who admitted on [DATE] and readmitted to facility on 9/15/23 with diagnoses including, atherosclerotic heart disease of native coronary artery without angina pectoris (is caused by plaque buildup in the wall of the arteries that supply blood to the heart (called coronary arteries). Plaque is made up of cholesterol deposits. Plaque buildup causes the inside of the arteries to narrow over time. This process is called atherosclerosis), type 2 diabetes (a chronic condition that happens when you have persistently high blood sugar levels), dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), hallucinations (involve seeing, hearing, feeling, tasting, or smelling things that aren't really there), Parkinson's disease (A disorder of the central nervous system that affects movement, often including tremors), hypertension (also known as high blood pressure, is a long-term medical condition in which the blood pressure in the arteries is persistently elevated), and gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach). Record review of Resident #1's revised care plan dated 10/10/23 indicated the following: Focus - Self-Care deficit: bathing, dressing, feeding due to terminal illness. Goal - staff will anticipate all needs. Interventions - Evaluate Resident #1s ability to perform ADLs, maintain consistent schedule with daily routine, provide assistance with ADLs, and Provide meal support per Resident #1's need. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated Resident #1 had difficulty communicating some words or finishing thoughts but was able if prompted or given time. Also, Resident #1 misses some part/intent of message but comprehends most conversation. She had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. Section GG: Resident #1 requires partial/moderate assistance with rolling left and right. Resident #1 was dependent, and helper did all of the effort for eating (assistance with utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident). Section GG also indicated Resident #1 was dependent for most ADLs. Record review of grievance/complaint report dated 12/11/23 indicated the following: Received by: The facility SW; Resident Representative - Relationship: Resident #1's family member; Grievance/complaint reported to: The facility SW; Describe grievance/complaint using factual terms: Staff at times not checking on Resident #1, not giving ice and water, not feeding Resident #1, not putting trapeze bar in her reach; Documentation of facility follow - up section: Individual(s) designated to take action on this concern; Date assigned; Time; Date to be resolved by; Was a group meeting held; Identify all individuals in attendance; Plan of care reviewed and updated date; questions were all BLANK and Not completed; What other action(s) were taken to resolve grievance/complaint (be specific)? Care plan scheduled for Friday 12/15/24 with department heads, Hospice, Ombudsman; and family rescheduled to 12/19/23 to accommodate all schedule. Resolution of Grievance/Complaint Section - Was grievance/complaint resolved: Yes, describe resolution; Care plan meeting held with family, ombudsman, and department leads on 12/19/23 to address issues/concerns. Report was signed at the bottom by both the Administrator and the SW and dated 12/19/23. Record review care plan meeting typed notes dated 12/19/23, attached to Resident #1's family member grievance report date 12/11/23 revealed the following: .The ombudsman asked Resident #1's family what the facility could do to fix the issues. Resident #1 stated she had brought the concerns to SW and ADON. She stated that the concerns were addressed at the time but feels they are patched and not fixed for good. Resident #1's family member stated she wanted the problems fixed. The Administrator explained that those current concerns were discussed during department head meeting after it was brought to their attention and that he was personally going in to check in on Resident #1. Resident #1's family members stated they had brought their concerns to CNAs and the nurses and they in turn stated they have reported the concerns to administration. The Ombudsman explained to Resident #1's family members to contact the Administration immediately upon any concerns. The DON and the Administrator let Resident #1's family know their information was posted in the facility for contacting them and that they can do so at any time. Resident #1's family member stated she knew everyone was busy and she hated to bother them. The Administrator and DON both stated to call them at any time. The DON explained their goal was to better care for Resident #1 and to build on the communication between the family and administration. She also asked Resident #1's family member to let administration know immediately of concerns. Resident #1's family member stated she that meeting had helped open up that communication and she felt better about her concerns and that they would be addressed. Resident #1's family member stated she would contact administration on concerns from then on. Record review of facility's grievance log revealed that grievances were not documented/filed on 01/26/2024 and 02/09/2024 on behalf of Resident #1. Record review of text messages dated 1/16/24 between Resident #1's family member to the Administrator and the DON stated we have another incident of Resident #1 not being properly fed. Family member is sending photos of the unknown staff bringing Resident #1 her food that evening. Then of that unknown staff sitting down to feed Resident #1 and a third picture of same unknown staff getting up and walking out and leaving Resident #1 food plate sitting open. The unknown staff left and never came back to feed Resident #1. A nightshift CNA said there were three residents on the same hall who were not fed. Y'all need more help on that hall. There were too many residents needing hands on care for one person. Who is the unknown staff in the pictures? Lastly, family member will send a picture of how Resident #1 was whenever another family member got there. Family member sent a second text message that stated Things seems to be headed right back down the wrong path again. What actions will you take to correct these issues? The DON responded She is a new aid that just started this week. Today was her first day out of orientation. I will get with her tomorrow as she is already gone tonight. Thank you for letting us know. Record review of text messages dated 2/09/24 between Resident #1's family member to the Administrator and the DON stated Question, what is the procedure for training these new aides for facility? Staff put Resident #1 in the recliner at 10am and no one had been in to put her back in her bed. Did not see an aide in Resident #1's room until 1pm for lunch. Charge nurse came in and sat up Resident #1 because she was slumped all the way over that evening, but no one had changed her pad since. That was part of the reason Resident #1 bottom kept getting open sores. A CNA came in and fed Resident #1 her dinner and came back to move Resident #1 back to bed whenever she finished feeding Resident #1. The night CNA needed help to tend to all the residents. Resident #1 had been in the same spot in her recliner since 10am, 9 hours. Unacceptable, Also the CNA who fed Resident #1 her lunch was talking on the phone to someone on her phone while feeding Resident #1. What happened to the no cell phone usage in residents' room? Things seemed to be headed backwards again. Resident #1 was completely soiled in poop, so much that it soiled the blanket she was sitting on in the chair. Completely unacceptable. The Administrator replied Unfortunately they could not be everywhere and see everything. Thank you for bringing it to their attention. All personnel go through the same orientation and appropriate on the job process. They will revisit and will keep working until they find the correct staff. The DON will follow up with her team. Resident #1's family member replied stating It was not about being everywhere, it was about the staff being trained appropriately and that you can trust that the CNAs were doing what they're supposed to. Again, this may come back to the chain of command, if the CNAs were not doing their jobs then someone should be checking on them throughout the day to make sure that the resident was not the one suffering. How would you like to sit in your own feces for no telling how long to the point that it bled through the blanket she was sitting on into the chair, that was a long time. Resident #1 has open sores on her bottom and the pad that was on her open sores was soiled all the way through to her skin. If anyone had taken the time to look, they would have seen she was soiled so badly you could tell from the front. The Administrator replied stating Thank you for bringing it to our attention. The DON will follow up with her team immediately. Record review of handwritten note dated 02/14/2024 revealed Resident #1's family member visited Resident #1 and asked the Administrator what was being done to correct the problems from last week, and the Administrator replied the DON was working on that. Resident #1's family member asked what the DON was working on, and the Administrator just repeated that the DON was working on it. During observation on 2/16/24 at 3:18 p.m., Resident #1 was lying in bed resting, she did not appear to be in pain at that time and was not able to answer questions asked. During an interview on 2/16/24 at 5:245 p.m., and via phone on 3/1/24 at 11:15 a.m., Resident #1's family member said a lot had changed since the facility hired the new Administrator and DON for the worse nearly a year ago. Resident #1's family member said she had voiced several complaints to the CNAs, but nothing was getting better, so she complained to the SW who scheduled a care plan meeting with all the department heads back in December 2023. Resident #1's family member said during the December 2023 care plan meeting the ombudsman, the Administrator and the DON told her to start notifying the Administrator and/or the DON personally regarding any issues/concerns and they would address it. Resident #1's family member said back on 1/26/24 and on 2/9/24 she had group texted the Administrator and the DON regarding issues/concerns and as of 3/1/24 the Administrator nor the DON had gotten back to her regarding her complaints to let her know what had been done. Resident #1's family member said on 2/14/24 she tried asking the Administrator what was being done about her complaint she made via text message to him on 2/9/24 and the Administrator would say the same response the DON was handling it; she said she questioned what the DON was doing, and the Administrator repeated DON was working on it. Resident #1's family member said she would love to know from Administration what was going on and what was being done because she was still having issues, and she felt like the facility did not care because she was not getting any answers from anyone. During an interview on 3/1/24 at 11:06 a.m., The Ombudsman said Resident #1's family has had numerous complaints about the care of Resident #1 that happened prior to the December 2023 big care plan meeting and was still going on. The Ombudsman said whenever Resident #1's family make a complaint, the first couple of days they attempted to improve care, but then thereafter it would go downhill. The Ombudsman said the Administrator mentioned that if Resident #1's family was not satisfied then they can move Resident #1. During an interview on 2/23/24 at 2:58 p.m., The DON said they had a care plan meeting in December 2023 with Resident #1`s family regarding several issues and concerns the family had. The DON said they were able to address Resident #1's family concerns and since the meeting Resident #1's family have voiced issues to other staff about having issues with staff not feeding Resident #1 and not turning Resident #1 every two hours. The DON was asked if she addressed the issues or concerns the other staff had brought to her and she said she felt Resident #1's family did not like her and that was why she did not follow up with the family regarding any of the issues, and she did not know if the Administrator had followed up with the family regarding their concerns/issues. During an interview on 2/23/24 at 3:23 p.m., The Social Worker said she was the grievance official who maintained the grievances. She said back on December 11, 2023 Resident #1's family member voiced several concerns to her and SW scheduled a care plan meeting for 12/13/24 to addressed the concerns with department heads and ombudsman. The SW said during the care plan meeting it was arranged/suggested for Resident #1's family to reach out directly to the DON and/or the Administrator moving forward with all concerns/issues. The SW said Resident #1's family had not come to her in 2024 regarding issues or concerns and she was not aware if Resident #1's family had reached out to the DON and/or the Administrator if they had then the DON nor the Administrator had told her. During an interview on 2/23/24 at 4:20 p.m., The Administrator said back in December 2023 all the department heads, the ombudsman and Resident #1's family members had a care plan meeting regarding all the concerns the family was having, and they were able to address most of the issues. During the meeting the Administrator said he told the Resident 1's family to personally let him and/or the DON know of any issues or concerns going forward and they would address it. The Administrator said Resident #1's family member had texted him and the DON a few times regarding concerns. The Administrator read off his phone the text messages from February 9, 2024 from Resident #1's family member to him and the DON; when the Administrator was asked if he notified or followed up with Resident #1's family about the status or the outcome from the concerns that were texted to him and he said he did not follow up with Resident #1's family and said the DON pretty much addressed everything. The administrator was asked how the DON addressed the issues Resident #1's family texted to them, and he could not answer what the DON did, and stated that he was sure the DON did something but did not know nor did he ask the DON what she did. The Administrator said Resident #1's family would normally reach out to him on a Friday evening, and he had five children at home, so he was not also able to immediately get back with the family, but he personally did not follow up with Resident #1's family with the outcomes. The Administrator said on 2/14/24 Resident #1's family member stopped him in the hall and asked what happened to the staff she complained about on 2/9/24 via text message, and he said he told her that it was confidential and could not disclose to her what happened to the staff. The Administrator was asked what happened to the staff he was referring to and he did not answer the question. The Administrator said he felt Resident #1's family had unrealistic expectations and said he told Resident #1's family if they were unhappy or had so many issues, they could take Resident #1 somewhere else. During an interview on 2/23/24 at 6:15 p.m., The DON said during the exit conference that she was not aware text messages needed to be followed up or was considered a complaint. Record review of revised Grievance policy dated December 2004 revealed facility will assist residents, their representatives (sponsors), other interested family members, or resident advocates in filing grievances or complaints when such requests are made. Policy Interpretation and Implementation: 1) Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc., without fear of threat or reprisal in any form. 2) Grievances and/or complaints may be submitted orally or in writing. Written complaints or grievances must be signed by the resident or the person filing the grievance or complaint on behalf of the resident. 3) The Social Worker has been delegated as the Grievance Official for the facility. Upon receipt of a written grievance and/or complaint, Designee will investigate the allegations and submit a written report of such findings to the QA committee. 4) The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need to be taken. 5) Should the resident not be satisfied with the result of the investigation, or the recommended actions, he or she may file a written complaint to the local ombudsman office or to the state survey and certification agency. Record review of the Rights of the Elderly included in the facility's revised new admission packet dated February 2023 revealed An elderly individual has all the rights, benefits, responsibilities, and privileges granted by the constitution and laws of this State and the United States, except where lawfully restricted. The elderly individual has the right to be free of interference, coercion, discrimination, and reprisal in exercising these civil rights. An elderly individual has the right to be treated with dignity and respect for the personal integrity of the individual, without regard to race, religion, national origin, sex, age, disability, marital status, or source of payment. This means that the elderly individual: . An elderly individual may complain about the individual's care or treatment. The complaint may be made anonymously or communicated by a person designated by the elderly individual. The person providing service shall promptly respond to resolve the complaint. The person providing services may not discriminate or take other punitive action against an elderly individual who makes a complaint.

Based on observation, interview, and record review the facility failed to ensure residents had the right to be free from neglect for 8 of 20 residents (Residents #5, #120, #121, #44, #119, #32, #38 and #220) reviewed for neglect. 1. The facility failed to effectively monitor Residents #'s #32, #38, #119, and #220 weights, to prevent weight loss, and nutritional deficits. Failed to input weekly weight orders. 2. The facility failed to provide daily wound care to prevent the decline in wound conditions for Residents #'s #120 and #121. Resident #'s 120 and 121 both had Stage 4 sacral wounds decline resulting in hospitalization s for wound infections. Resident #121 died on [DATE] during his hospitalization . 3. The facility failed to implement dietary recommendations timely for Resident #121. 4. The facility failed to provide and maintain offloading devices for Residents #'s #120 and #121. 5. The facility failed to educate the nurses providing wound care. 6.Failed to input wound care orders in the computer system to be completed by the treatment nurses, nurses, or weekend nurses. 7. The facility failed to prevent Resident #5 from obtaining 2 new pressure injuries (DTIs) to both feet. 8. The facility failed to monitor and obtain Resident #44's anticoagulant laboratory results since [DATE]. 9. The facility failed to implement admission orders ensuring residents received the necessary care and services for: 22 of 80 residents with orders in the queue for implementation. 10. The facility failed to implement dietician recommendations timely for Resident #220. 11. The facility failed to implement heel protectors for Resident #5 while in bed according to the physician's orders. 12. The facility did not identify or document the onset or follow treatment orders for the left thumb of Resident #49 after a stage 2 pressure injury was identified by an outside agency. 13. The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35. 14. The facility failed to obtain Resident #34's Vancomycin (is used to treat infections caused by bacteria. It works by killing bacteria or preventing their growth) trough level (is drawn immediately before the next dose of the drug is administered because it is the lowest concentration in the patient's bloodstream) as ordered prior to administration of first dose of Vancomycin. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 1:20 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern with the severity of actual harm that was not immediate jeopardy, with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures placed residents at risk for negative outcomes and including death. Findings included: Record review of the CMS 672, dated [DATE], indicated in Section G, other. F140 1 resident with unplanned significant weight loss/gain. 1.) Record review of Resident #32's face sheet, dated [DATE], indicated Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of stroke, pain, seizures, dysphagia (difficulty swallowing) and malnutrition (lack of nutrition). Record review of Resident #32's consolidated physician's orders, dated [DATE], indicated Resident #32 had a diet order of mechanical soft and nectar thickened fluids, dated [DATE], and a magic cup with lunch and dinner, dated [DATE]. Record review of Resident #32's computerized weights indicated her weight was 153.8 pounds on [DATE] and 141.1 pounds on [DATE]. Record review of a comprehensive care plan dated [DATE] and revised on [DATE] indicated Resident #32 required assistance with her ADLs including assistance with eating, with staff to feed Resident #32 if she was unable to complete the task. The care plan indicated Resident #32 was at risk for weight loss with the goal of maintaining her current level of weight through [DATE]. The interventions included monitor for signs of malnutrition, a weight every month, and report a loss or gain of more than 5%. The comprehensive care plan also indicated Resident #32 was receiving a therapeutic diet and was at risk for nutritional deficit. The goal was Resident #32 would consume adequate fluid and would consume 75% or more of the meals served with no associated weight loss through next review dated [DATE]. The interventions included administer snacks, and supplements as ordered, and provide a magic cup with lunch and dinner dated [DATE]. Record review of an Annual MDS dated [DATE] indicated Resident #32 was sometimes understood and sometimes understands, and Resident #32's BIMs score was 00 indicating severe cognitive impairment. The MDS indicated Resident #2 required total assistance of one staff with meals. The MDS in Section K indicated Resident #32 did not have a swallow disorder or signs of a swallowing disorder. Section K also indicated Resident #32's height was 70 inches, and her weight was 147 lbs. with no weight loss or weight gain documented. Record review of a weight record, dated ,d+[DATE] ,d+[DATE], indicated Resident #32's weight 180 days prior was 151.8 pounds, 90 days prior the weight was 152.8 pounds, and on [DATE] Resident #32's weight was 141.1 pounds. During observations on [DATE] - through [DATE] for Resident #32 revealed the following: -On *[DATE] at 12:55 p.m., there was no supplement with the Resident #32's lunch meal. -On *[DATE] at 5:55 p.m., there was no magic cup with her Resident #32's evening tray. - On *[DATE] at 12:25 p.m., there was no magic cup with her Resident #32's lunch tray. -On *[DATE] at 6:00 p.m., there was no supplement with her Resident #32's evening tray. Record review of the dietician reports revealed the following: -On *[DATE], there was: no mention of recommendations for weekly weights for Resident #32. -On *[DATE], there was: no mention of recommendations for weekly weights for Resident #32. -On *[DATE], there was: no mention of recommendations for weekly weights for Resident #32. -On *[DATE], there was: no mention of recommendations for weekly weights for Resident #32. - On *[DATE], there was: no mention of recommendation for weekly weights for Resident #32. On *[DATE] and [DATE], there was: no mention of recommendations for weekly weights for, Resident #32. 2.) Record review of Resident #38's face sheet, dated [DATE], indicated Resident #38 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis diagnoses which included of stroke, diabetes (too much sugar in the blood), chronic kidney disease (longstanding disease of the kidney), and muscle weakness. Record review of the consolidated physician orders, dated [DATE], indicated Resident #38 did not have a diet ordered. Resident #38 had orders in a que including which included the diet order waiting for processing. Record review of Resident #38's comprehensive care plan, dated [DATE], revealed there was no care plan addressing the risk of weight loss or actual weight loss. Record review of the clinical records for Resident #38 indicated the Initial MDS was not completed. Record review of Resident #38's computerized weights indicated on [DATE] his weight was 225.0 pounds, and his weight was 190.8 pounds on [DATE]. Record review of a dietician's consultant, dated [DATE], indicated Resident #38 had no recommendations even though the weights indicated he had already lost 25 pounds. Record review of a dietician's consultant report dated [DATE] indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated [DATE] indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated [DATE] indicated Resident #38 was not evaluated. Record review of a dietary profile dated [DATE] indicated Resident #38 was receiving a regular diet with no dietary supplements. 3.) Record review of Resident #119's face sheet, dated [DATE], indicated Resident #119 was an [AGE] year-old female who was admitted to the facility on [DATE] with the diagnoses of which included joint replacement surgery, muscle weakness, and high blood pressure. Record review of the Admission MDS, dated [DATE], indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11, indicating which indicated she had moderate impairment with cognition. The MDS indicated Resident #119 required extensive assistance of one staff member with eating. The Section GG of the MDS indicated Resident #119 was independent eating with no assistance. The MDS indicated Resident #119's weight was 130 pounds in the section K0200. The MDS indicated Resident #119 had no weight loss or weight gain in the section of K0300. Record review of a hospital medication consolidation record dated [DATE], indicated on [DATE] Resident #119's weight was 160 pounds, and her height was 62 inches. Record review of a Dietary Profile dated [DATE] indicated Resident #119 was receiving a regular diet and did not require any nutritional supplements. Record review of Resident #119's weights indicated only one weight was obtained since admission on [DATE] of 130 pounds. Record review of the Dietician Recommendation indicated on [DATE] Resident #119 had no recommendations. Record review of a Dietician Progress Note dated [DATE] indicated Resident #119 was eating ,d+[DATE] % of meals, her weight was 130 pounds and stable. The note also indicated Resident #119 had no skin issues. The notes comments indicated the diet was regular diet with thin liquids, to maintain weight without significant change over the next three months and to continue current diet. The dietician note does not indicate there was a significant weight loss from the hospital weight of 160 pounds and the facility weight of 130 pounds. Record review of the dietician reports revealed the following: - On *[DATE] and [DATE], there was: no mention of recommendations for weekly weights for Resident #'s #119. Record review of the comprehensive care plan dated [DATE] indicated Resident #119 was receiving a regular diet with the goal of her weight remaining stable through the next review. The interventions included allow choices in food items, and provide snacks or supplements as ordered. During an observation on [DATE] Resident #119 had consumed 50 % of her meal while in her bed. Record review of the consolidated physician's orders dated [DATE] indicated Resident #119's diet was a regular diet with thin liquids started [DATE]. During an interview with the DON on [DATE] at 3:26 p.m., the DON said she inputs the resident's weights in the computer after their weight was obtained. The DON said the person obtaining the weights just logged the weight obtained. The DON said when she reviews reviewed the weights and, she stars starred them for a reweight to verify the changes. The DON said the hospital weights were often not correct therefore it was important to have a weight. The DON indicated all the systems were a process. During an interview on [DATE] at 2:24 p.m., the ADON A indicated there were no weekly standards of care meetings to review each resident with wounds, weight loss, labs, or accidents. ADON A said she had mentioned this to the management team but was not considered. ADON A said the standards of care meetings was a review of the resident to ensure all the care areas were met. During an interview on [DATE] at 1:36 p.m., LVN L indicated residents should be weighed on admission and monthly. LVN L indicated with not knowing the admission weight there could be a weight loss leading to skin problems, and even the loss of mobility. During an interview on [DATE] at 2:39 p.m., the Regional Nurse Consultant indicated she was unaware of weight loss issues. The Regional Nurse Consultant new admissions should have a weight once a week for 4 weeks or until stable. The corporate nurse indicated the admitting nurse was responsible for obtaining the admission weight. The Regional Nurse indicated there was not a reason for the admission or weekly weights not being obtained. The Regional Nurse Consultant said the DON was responsible for the weight management program. During an interview on [DATE] at 4:55 p.m., the Interim Administrator indicated the physician should be notified when the resident's weight falls fell in the parameter areas of 5% in one month, 7.5% in 3 months and 10% in 6 months either a loss or a gain. The Interim Administrator indicated health issues could arise when weights were not monitored. The Interim Administrator indicated the charge nurses, and DON were responsible for the monitoring of weights. Record review of a Nutritional Management policy, dated [DATE], indicated the facility provides care and services to each resident to ensure the residents maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. C. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Record review of the facility's Weight Monitoring policy, dated [DATE], indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. 5. A weight monitoring schedule will be developed upon admission for all residents: A. Weights should be recorded at the time obtained. B. newly admitted residents-monitor weight weekly for 4 weeks, Residents with weight loss -monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. 4) Record review of Resident #121's face sheet, with the printed date of [DATE], indicated Resident #121 was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnoses of which included sepsis (severe complication of an infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric needs). Record review of Resident #121's The Admission MDS revealed it was not completed. Record review of a Resident #121's Baseline Care Plan, dated [DATE], indicated Resident #121 required extensive assistance with his ADLs, he had a skin concern of a pressure ulcer to the sacrum, with the goals of the wound to show signs of healing with area decreasing in overall size. The interventions included to provide the wound care/preventative skin care, weekly skin checks, turn and reposition, and notify the physician of any changes in the wound or emerging wounds. The physician orders listed in Section M of the Baseline Care plan did not reveal a wound care order with the medication orders. Record review of Resident #121's Admission-Readmission Assessment, dated [DATE], indicated Resident #121 was admitted to the facility on [DATE] from a hospital. The assessment indicated Resident #121 had a pressure injury to his vertebrae (upper-mid back) measuring 0.2 cm x 0.2 cm x undetermined depth, a coccyx pressure ulcer measuring 0.5 cm x 0.4 cm x undetermined, and a pressure ulcer to the left buttock measuring 0.5 cm x 0.5 cm x undetermined depth. Record review of a Skin and Wound -total Body Skin Assessment, dated [DATE] on admission, indicated Resident #121's skin turgor (skin elasticity) had poor elasticity, the skin color was normal, temperature was cool, the moisture was normal, the condition dry, and had 3 new wounds. The wounds were not specified in the assessment. Record review of a Braden Scale for Prediction Pressure Sore Risk, dated [DATE], indicated Resident #121 had no sensory perception impairment, he was occasionally moist, and he was chair fast with the ability to walk severely limited. The assessment indicated Resident #121 was slightly limited making frequent though slight changes in body or extremity positions independently, his nutrition was probably inadequate, and he required moderate to maximum assistance with moving. Resident #121's score was 15, indicating which indicated the resident was at risk for developing pressure sores. Record review of a Daily Skilled Note, dated [DATE], indicated Resident #121's indicated his skin was dry, he consumed 75% of meals, consumes consumed a regular diet with thin liquids. The note did not indicate there were no other skin problems. The skin condition section (6f) of the note failed to indicate pressure ulcers were present. Record review of a Dietician Recommendation, dated [DATE], indicated Resident #121 was recommended to have Pro stat 30 milliliters twice a day due to his albumin level (protein in the blood) was 2.8 with the normal range of 3.4 to 5.4. Record review of a Daily Skilled Note, dated [DATE], indicated Resident #121 had fair, dry and fragile skin. The note indicated Resident #121 fed himself and his intake was 75% or more each meal. The skin condition section of the note failed to indicate 6f. pressure ulcers were present. Record review of a Skin assessment dated [DATE], indicted Resident #121's sacral wound measured 4.0 cm x 3.0 cm x 0.1 cm and was a stage 4 pressure ulcer. The skin assessment report indicated the wound was 100% slough (dead tissue) with a light serous drainage. Record review of an Initial Wound Evaluation and Management Summary, dated [DATE], indicated Resident #121 had a Stage 4 full thickness pressure wound to the sacrum measuring 4.0 cm x 3.0 cm x 0.1 cm. The wound was 100% slough (dead tissue) with a light serous drainage. The wound physician recommended leptospermum honey apply once daily for 30 days, cover with a gauze island with border dressing once daily. The Wound Evaluation indicated Resident #121 had a surgical excisional debridement procedure to remove necrotic tissue and establish margins of viable tissue. The additional note of the wound evaluation indicated post-debridement assess of the previously unstageable necrotic wound had been obscured by necrosis prior to this point. The wound now reveals itself to be a Stage 4 pressure injury. The Wound Evaluation's Treatment Plan indicated leptospermum honey would be applied once daily covered with a secondary dressing with a border. The recommendations included off-load the wound, limit sitting to 60 minutes, reposition according to facility protocol turn side to side and front to back in bed every ,d+[DATE] hours if able, a group 2 mattress, multivitamin daily, vitamin C 500 milligrams twice daily by mouth and zinc sulfate 220 mg once daily by mouth for 14 days. Record review of the medication administration record, dated [DATE], failed to indicate the initial administration and ongoing administration of Vitamin C 500 mg twice daily by mouth or the zinc sulfate 220 mg once daily by mouth for 14 days. The medication administration record indicated the recommendations were started on [DATE], 8 days after the recommendation was given by the dietician. Record review of Resident #121's consolidated physician's orders dated [DATE]-[DATE], failed to indicate a low air loss mattress was ordered with appropriate setting to reflect his actual weight. Record review of the Resident #121's [DATE] Treatment Administration Record indicated Resident #121 had no treatment to his sacral wound until after the wound care physician made his first visit on [DATE]. Resident #121's treatment record indicated there were no previous treatments to his sacral ulcer for 15 days. Record review of a Skin Assessment, dated [DATE], indicated Resident #121's sacral wound measured 3.5 cm x 3.0 cm x 0.1 cm and was considered a stage 4 pressure ulcer. The skin assessment indicated the wound had a light serous drainage and was 100% slough (dead tissue). Record review of a [DATE] of a treatment administration record, indicated Resident #121's treatment to his sacral pressure ulcer was missed on [DATE] and [DATE]. During an interview on [DATE] at 3:00 p.m., ADON A said she had sent Resident #121 to the emergency room related to increase pain to his sacral ulcer. Record review of the Resident #121's progress note, dated [DATE] at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain. Record review of Resident #121's comprehensive care plan did not reflect a potential impairment of the skin until [DATE]. The care plan indicated Resident #121 had the potential for impaired skin integrity related to decreased mobility, and low protein intake. The goal was to show no evidence of skin breakdown through the next review with the interventions of applying a barrier cream as needed, Braden risk assessment per facility protocol, encourage adequate nutrition and hydration, and keep Resident #121 clean, dry, and sheets wrinkle free, all dated [DATE]. The comprehensive care plan, dated [DATE], indicated Resident #121 had a stage 4 pressure ulcer or the potential for pressure ulcer development related to impaired mobility. The goal was Resident #121's pressure ulcer would show signs of healing and remain free from infection. The interventions were to administer the treatment per the physician orders, do not massage over boney prominences, and use mild cleaners for peri-care. The other intervention, dated [DATE], indicated Resident #121 required turning and repositioning every 2 hours, or more often as needed or requested. Record review of the [DATE] medication administration record indicated Resident #121 had an order for that stated cleanse stage 4 to sacrum and apply leptospermum honey cover with a border gauze once daily. The treatment administration record indicated Resident #121 missed a treatment on [DATE], and [DATE]. Record review of a Weekly Wound Tracking Worksheet dated [DATE] -[DATE], indicated Resident #121 had a Stage 4 pressure wound to his sacrum, with light serous drainage, measuring 4.0 cm x 3.0 cm x 0.1 cm, with the treatment was Medi-honey with a bordered dressing. The form indicated Resident #121 was on the corona virus unit during this assessment period. Record review of the progress note, dated [DATE] at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain. During an observation and interview on [DATE] at 10:59 a.m., Resident #121 was sitting up in his wheelchair. Resident #121 said his wound on his bottom was hurting and he was administered a pain medication. Resident #121 said his wound care had not been completed. Resident #121's bed sheets had blood-tinged drainage on the sheets approximately where his bottom would have been. During an interview on [DATE] at 8:45 a.m., ADON A was asked to see the wound care for Residents #'s #120 and #121. ADON A said all treatments had been done for the day. Record review of a Hospitalist Admission Note, dated [DATE], indicated Resident #121's diagnoses included Sepsis secondary to an unstageable sacral decubitus wound and acute on chronic kidney disease lll likely from the sepsis and congestive heart failure. The note indicated the Cat Scan (CT) of the abdomen/pelvis was positive for subcutaneous gas (gas gangrene a potentially deadly form of tissue death). The note indicated Resident #121 was placed on three broad spectrum antibiotics Vancomycin, cefepime, and clindamycin. The note indicated Resident #121 was referred to the general surgeon for wound debridement. The chief complaint was generalized body aches/pain and a worsening decubitus ulcer. The note indicated in the emergency room the sacral ulcer was foul-smelling. The note indicated he was in no acute distress at rest but does did have exquisite pain on any passive movement due to extensive sacra decubitus wound. The laboratory results listed on the admission note indicated Resident #121's white blood cell count was 16.9 (High) with normal range of 4,000 - 11,000/microliters indication of infection, (Albumin level) 1.8 (low) with normal range of 3.4 to 5.4 g/dl, and BUN (Blood urea nitrogen) was 52 (High) normal range 6 to 24 mg/dl indicating which included his kidneys were not functioning well. Record review of a CT (cat scan) of the pelvis, dated [DATE], indicated subcutaneous defect at the sacrum, with scattered subcutaneous gas about the sacrum at midline, as well as subcutaneous gas within the gluteal musculature bilaterally, left greater than right, with surrounding cellulitis. Findings were concerning for gas-forming infection as can could be seen in the setting of necrotizing fasciitis (flesh eating disease). During a record review of the ER record dated [DATE], a picture taken on arrival to the ER displayed a large sacral wound with base of wound covered with 80% in slough and eschar and the base of the spinal column was exposed. During an observation and interview on [DATE] at 11:30 a.m., Resident #121 was noted to be on the ER gurney at the local ER. Resident #121 stated he had been on the gurney for a day and was waiting a hospital bed because he was being admitted to the hospital for a wound infection. Resident #121 stated he had a large wound on his sacrum that was to the bone. Resident #121 stated it was painful and would not allow visualization of the wound. Resident #121 stated the pressure ulcer had gotten worse since he developed it because he was not being turned and he had gone multiple days with no treatment. During an interview on [DATE] at 12:30 p.m., the hospital SW stated the hospital was running test for sepsis and the resident was being admitted for a wound infection. Record review of a Hospital History and Physical dated [DATE] at 6:17 p.m., indicated Resident #121 was admitted to the hospital for severe sepsis (severe life-threatening complication of an infection secondary because of an infection to an unstageable pressure ulcer. The note indicated Resident #121 was started on two antibiotics for the pressure ulcer infection. The history and physical also indicated Resident #121 was in an acute on chronic kidney failure condition related to the sepsis. The history and physical note indicated in the emergency room , Resident #121's sacral pressure ulcer was foul smelling, extensive, and positive for gases (gas produced by dying tissue). Record review of a Death Summary note, dated [DATE], indicated Resident #121 was treated with pain medication and anxiety medication and died peacefully in the night. The note indicated Resident #121 had intractable pain and the family agreed to make him a do not resuscitate and placed him on palliative care with the intent of discharging to a nursing facility with hospice care. 5) Record review of a Resident #120's face sheet, dated [DATE], indicated Resident #120 was a [AGE] year-old male who admitted to the facility on [DATE] with the diagnosis diagnoses which included of bacterial peritonitis (infection of the peritoneal cavity), severe sepsis with septic shock (a life-threatening complication of infection), and an unstageable pressure ulcer of the sacral region (low back). Record review of Resident #120's admission assessment dated [DATE], indicated he had a sacral wound with no measurements included. Record review of a Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated he was at risk for pressure injuries. Record review of a Resident #120's Baseline Care Plan, dated [DATE], indicated Resident #120 required extensive assistance of one staff for walking, toileting, locomotion, grooming, bathing, and set up help with eating. The care plan for bed mobility was left blank. The care plan indicated Resident #120 had a surgical wound, pressure ulcer, specify locations of treatment ordered (sacrum, upper back, and abdomen). The goal was the wounds would show signs of healing with area decreasing in overall size. The interventions included skin checks weekly, turn, and reposition frequently to decrease pressure, and wound vac. Record review of the Resident #120's admission-readmission assessment, dated [DATE], indicated Resident #120 had alterations in skin integrity. The assessment indicated he had a sacral pressure wound and an abdominal surgical incision. The assessment had no measurements of Resident #120's wounds. Record review of the [DATE] EMR wound care entry for Resident #120's sacral wound indicated the wound care was not performed on [DATE], [DATE], [DATE], [DATE], and [DATE]. Record review of Resident #120's skin assessment dated [DATE], indicated he had a stage 4 sacral pressure ulcer measuring 10cm x 10cm x 4cm. Record review of a Resident #120's Dietician Progress Note and Recommendations, dated [DATE], indicated Resident #120 was recommended to receive Juven (dietary supplement to enhance wound healing) twice daily. Record review of Resident #120's EMR indicated the dietician recommendation of Juven 1 package twice daily was not implemented but another Arginaid (dietary supplement to enhance wound healing) one packet twice a day was ordered and implemented on [DATE]. Record review of an Initial Wound Evaluation and Management Summary, dated [DATE], indicated Resident #120 had a stage 4 pressure wound to the sacrum measuring 10 cm x 10 cm x 4 cm with 30% of the wound bed slough, 40% granulation tissue, and 30% muscle, facia, and/or bone. The wound care physician recommended off-loading of the wound, and to turn side to side every ,d+[DATE] hours, if able. The wound care note indicated the dressing treatment plan was Dakin's solution apply once daily, cover with abdominal pad. The wound care note indicated the wound care physician performed surgical removal of the devitalized tissue including slough, biofilm, and no-viable periosteum and bone were removed at a depth of 4 cm. During an observation on [DATE] at 11:09 a.m., Resident #120 was lying flat on his back on his bed, the wound vacuum was sitting in his wheelchair. Resident #120 said he had been at the facility for 5 days. During an observation and interview on [DATE] at 4:45 p.m., ADON A said Resident #120's wound vacuum will would not seal well due to the proximity to Resident #120's colostomy bag. ADON A indicated she would have to notify the physician for orders. Resident #120 was lying flat on his back. Resident #120's body reaches reached from side to side of the mattress. During an observation on [DATE] at 8:20 a.m., Resident #120 way lying in his bed on a standard hospital bed mattress. Residen [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 20 residents (Residents #5, #49, #120, and #121) reviewed for pressure injury. *The facility failed to provide wound care to Resident #121s sacral pressure injury until [DATE], which was 15 days after his admission with pressure injuries. *The facility failed to consistently provide wound care for Resident #121 after beginning wound care, missing treatments on [DATE] and [DATE]. *The facility failed to implement a dietician recommendations of Pro-stat (given to provide body with additional protein to promote healing) for Resident #121 on [DATE] until [DATE] , 8 days after the recommendation was made. *The facility failed to administer the initial and on-going minerals and vitamins to Resident #121 as ordered by the wound care physician on [DATE]. *Resident #121's sacral wound deteriorated and increased in size from 0.5 cm x 0.4 cm x undetermined depth on [DATE] to 4.0 cm x 3.0 cm x 0.1 cm on [DATE]. Resident developed an infection in his wound and was admitted to the hospital [DATE] with a diagnosis of sepsis secondary to an unstageable sacral decubitus wound. Resident # 121 died [DATE]. *The facility failed to measure Resident #120's sacral wound upon admission. *The facility failed to implement the wound care physician's orders to offload Resident #120's pressure ulcer. *The facility failed to provide Resident #120 a low air loss mattress to prevent wound decline. *The facility failed to provide daily wound care to Resident # 120's sacral wound as ordered on [DATE], [DATE], [DATE], and [DATE]. *The facility failed to prevent Resident #120's wound from becoming infected requiring which required hospitalization . *The facility failed to prevent Resident #5 from developing two new DTIs (deep tissue injuries), one on her left inner bottom of her foot, and one on the right outer foot. (DTIs caused from bilateral feet pressure against each other) The facility failed to document newly identified DTIs and implement treatment orders for Resident #5 when the wound care physician identified the new wounds on [DATE]. *The facility failed to identify the onset or followup orders for the left thumb of Resident #49 which resulted in a stage 2 pressure injury. An immediate Jeopardy (IJ) situation was identified on [DATE] at 4:35 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of a pattern with actual harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the effectiveness of the corrective systems. These failures placed residents at risk of pain, worsening of wounds, wound infection, emotional distress, harm or even death. Findings included: 1. Record review of Resident #121's face sheet, with the printed date of [DATE], indicated a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Sepsis (severe complication of an infection) due to pneumonia, muscle weakness, acute kidney failure, high blood pressure, and malnutrition (lack of caloric intake). Record review of Resident #121's The Admission MDS revealed it was not completed. Record review of a Resident #121's Baseline Care Plan, dated [DATE], indicated Resident #121 required extensive assistance with his ADLs, he had a skin concern of a pressure ulcer to the sacrum, with the goals of the wound to show signs of healing with area decreasing in overall size. The interventions included to provide the wound care/preventative skin care, weekly skin checks, turn and reposition, and notify the physician of any changes in the wound or emerging wounds. The physician orders listed in Section M of the Baseline Care plan did not reveal a wound care order with the medication orders. Record review of an Admission-Readmission Assessment, dated [DATE], indicated Resident #121 was admitted to the facility on [DATE] from a hospital. The assessment indicated Resident #121 had a pressure injury to his vertebrae (upper-mid back) measuring 0.2 cm x 0.2 cm x undetermined depth, a coccyx pressure ulcer measuring 0.5 cm x 0.4 cm x undetermined, and a pressure ulcer to the left buttock measuring 0.5 cm x 0.5 cm x undetermined depth. Record review of a Skin and Wound -total Body Skin Assessment, dated [DATE], indicated Resident #121's skin turgor (skin elasticity) had poor elasticity, the skin color was normal, temperature was cool, the moisture was normal, the condition dry, and had 3 new wounds. The wounds were not specified in the assessment. Record review of a Fall Risk Assessment, dated [DATE], indicated Resident #121 did not display resisting of care, he would eliminate with assistance, and required hands on assistance with moving from place to place. Record review of a Braden Scale for Prediction Pressure Sore Risk, dated [DATE], indicated Resident #121 had no sensory perception impairment, he was occasionally moist, and he was chair fast with the ability to walk severely limited. The assessment indicated Resident #121 was slightly limited making frequent though slight changes in body or extremity positions independently, his nutrition was probably inadequate, and he required moderate to maximum assistance with moving. Resident #121's score was 15, indicating which indicated the resident was at risk for developing pressure sores. Record review of a Daily Skilled Note, dated [DATE], indicated Resident #121 indicated his skin was dry, he consumed 75% of meals, consumed a regular diet with thin liquids. The note did not indicate there were no other skin problems. The skin condition section of the note failed to indicate 6f. pressure ulcers were present. Record review of a Dietician Recommendation, dated [DATE], indicated Resident #121 was recommended to have Pro stat 30 milliliters twice a day due to his albumin level (protein in the blood) was 2.8 with the normal range of 3.4 to 5.4. Record review of the Resident #121's [DATE] Treatment Administration Record indicated Resident #121 had no treatment to his sacral wound until after the wound care physician made his first visit on [DATE]. Resident #121's treatment record indicated there were no previous treatments to his sacral ulcer for 15 days. Record review of the [DATE] medication administration record indicated the recommendations were started on [DATE], 8 days after the recommendation was given by the Dietician. Record review of a Daily Skilled Note, dated [DATE], indicated Resident #121 had fair, dry and fragile skin. The note indicated Resident #121 fed himself and his intake was 75% or more each meal. The skin condition section of the note failed to indicate 6f. pressure ulcers were present. Record review of a Skin assessment dated [DATE], indicted Resident #121's sacral wound measured 4.0 cm x 3.0 cm x 0.1 cm and was a stage 4 pressure ulcer. The skin assessment report indicated the wound was 100% slough (dead tissue) with a light serous drainage. Record review of an Initial Wound Evaluation and Management Summary, dated [DATE], indicated Resident #121 had a Stage 4 full thickness pressure wound to the sacrum measuring 4.0 cm x 3.0 cm x 0.1 cm. The wound was 100% slough (dead tissue) with a light serous drainage. The wound physician recommended leptospermum honey apply once daily for 30 days, cover with a gauze island with border dressing once daily. The Wound Evaluation indicated Resident #121 had a surgical excisional debridement procedure to remove necrotic tissue and establish margins of viable tissue. The additional note of the wound evaluation indicated post-debridement assess of the previously unstageable necrotic wound had been obscured by necrosis prior to this point. The wound now reveals itself to be a Stage 4 pressure injury. The Wound Evaluation's Treatment Plan indicated leptospermum honey would be applied once daily covered with a secondary dressing with a border. The recommendations included off-load the wound, limit sitting to 60 minutes, reposition according to facility protocol turn side to side and front to back in bed every ,d+[DATE] hours if able, a group 2 mattress, multivitamin daily, vitamin C 500 milligrams twice daily by mouth and zinc sulfate 220 mg once daily by mouth for 14 days. Record review of Resident #121's consolidated physician's orders dated [DATE]-[DATE], failed to indicate a low air loss mattress was ordered with appropriate setting to reflect his actual weight. Record review of the medication administration record, dated [DATE], failed to indicate the initial administration and ongoing administration of Vitamin C 500 mg twice daily by mouth or the zinc sulfate 220 mg once daily by mouth for 14 days. The medication administration record indicated the recommendations were started on [DATE], 8 days after the recommendation was given by the dietician. Record review of a Daily Skilled Note, dated [DATE], indicated Resident #121 had dry skin. In the section of 6f. of the Daily Skilled Note there were no pressure ulcers documented. Record review of a Wound Evaluation and Management Summary, dated [DATE], indicated Resident #121's sacral wound remained a stage 4 full thickness wound. The wound measured 3.5 cm x 3.0 cm x 0.1 cm, with 100% slough. The recommendations continued to be the multivitamin daily, Vitamin C 500 mg twice daily by mouth and zinc sulfate 220 mg once daily by mouth for 14 days. The wound note indicated Resident #121's wound was surgically debrided removing the necrotic tissue and establish margins of viable tissue. The treatment was leptospermum honey cover with a gauze island dressing with a border once daily. Record review of a Skin Assessment , dated [DATE], indicated Resident #121's sacral wound measured 3.5 cm x 3.0 cm x 0.1 cm and was considered a stage 4 pressure ulcer. The skin assessment indicated the wound had a light serous drainage and was 100% slough (dead tissue). Record review of a [DATE] of a treatment administration record, indicated Resident #121's treatment to his sacral pressure ulcer was missed on [DATE] and [DATE]. Record review of Resident #121's comprehensive care plan did not reflect a potential impairment of the skin until [DATE]. The care plan indicated Resident #121 had the potential for impaired skin integrity related to decreased mobility, and low protein intake. The goal was to show no evidence of skin breakdown through the next review with the interventions of applying a barrier cream as needed, Braden risk assessment per facility protocol, encourage adequate nutrition and hydration, and keep Resident #121 clean, dry, and sheets wrinkle free, all dated [DATE]. The comprehensive care plan, dated [DATE], indicated Resident #121 had a stage 4 pressure ulcer or the potential for pressure ulcer development related to impaired mobility. The goal was Resident #121's pressure ulcer would show signs of healing and remain free from infection. The interventions were to administer the treatment per the physician orders, do not massage over boney prominences, and use mild cleaners for peri-care. The other intervention, dated [DATE], indicated Resident #121 required turning and repositioning every 2 hours, or more often as needed or requested. Record review of the [DATE] medication administration record indicated Resident #121 had an order for that stated cleanse stage 4 to sacrum and apply leptospermum honey cover with a border gauze once daily. The treatment administration record indicated Resident #121 missed a treatment on [DATE], and [DATE]. Record review of a Weekly Wound Tracking Worksheet dated [DATE] -[DATE], indicated Resident #121 had a Stage 4 pressure wound to his sacrum, with light serous drainage, measuring 4.0 cm x 3.0 cm x 0.1 cm, with the treatment was Medi-honey with a bordered dressing. The form indicated Resident #121 was on the corona virus unit during this assessment period. Record review of the progress note, dated [DATE] at 3:34 p.m., indicated Resident #121 was sent to the local hospital for increased confusion, and increased pain. During an observation and interview on [DATE] at 10:59 a.m., Resident #121 was sitting up in his wheelchair. Resident #121 said his wound on his bottom was hurting and he was administered a pain medication. Resident #121 said his wound care had not been completed. Resident #121's bed sheets had blood-tinged drainage on the sheets approximately where his bottom would have been. During an interview on [DATE] at 8:45 a.m., ADON A was asked to see the wound care for Residents #'s #120 and #121. ADON A said all treatments had been done for the day. During an interview on [DATE] at 3:00 p.m., ADON A said she had sent Resident #121 to the emergency room related to increase pain to his sacral ulcer. During a record review of the ER record dated [DATE], a picture taken on arrival to the ER displayed a large sacral wound with base of wound covered with 80% in slough and eschar and the base of the spinal column was exposed. During an observation and interview on [DATE] at 11:30 a.m., Resident #121 was noted to be on the ER gurney at the local ER. Resident #121 stated he had been on the gurney for a day and was waiting a hospital bed because he was being admitted to the hospital for a wound infection. Resident #121 stated he had a large wound on his sacrum that was to the bone. Resident #121 stated it was painful and would not allow visualization of the wound. Resident #121 stated the pressure ulcer had gotten worse since he developed it because he was not being turned and he had gone multiple days with no treatment. Record review of a Hospitalist Admission Note, dated [DATE], indicated Resident #121's diagnoses included Sepsis secondary to an unstageable sacral decubitus wound and acute on chronic kidney disease lll likely from the sepsis and congestive heart failure. The note indicated the Cat Scan (CT) of the abdomen/pelvis was positive for subcutaneous gas (gas gangrene a potentially deadly form of tissue death). The note indicated Resident #121 was placed on three broad spectrum antibiotics Vancomycin, cefepime, and clindamycin. The note indicated Resident #121 was referred to the general surgeon for wound debridement. The chief complaint was generalized body aches/pain and a worsening decubitus ulcer. The note indicated in the emergency room the sacral ulcer was foul-smelling. The note indicated he was in no acute distress at rest but does did have exquisite pain on any passive movement due to extensive sacra decubitus wound. The laboratory results listed on the admission note indicated Resident #121's white blood cell count was 16.9 (High) with normal range of 4,000 - 11,000/microliters indication of infection, (Albumin level) 1.8 (low) with normal range of 3.4 to 5.4 g/dl, and BUN (Blood urea nitrogen) was 52 (High) normal range 6 to 24 mg/dl indicating which included his kidneys were not functioning well. Record review of a CT (cat scan) of the pelvis, dated [DATE], indicated subcutaneous defect at the sacrum, with scattered subcutaneous gas about the sacrum at midline, as well as subcutaneous gas within the gluteal musculature bilaterally, left greater than right, with surrounding cellulitis. Findings were concerning for gas-forming infection as can could be seen in the setting of necrotizing fasciitis (flesh eating disease). During an interview on [DATE] at 12:30 p.m., the hospital SW stated the hospital was running test for sepsis and the resident was being admitted for a wound infection. Record review of a Hospital History and Physical dated [DATE] at 6:17 p.m., indicated Resident #121 was admitted to the hospital for severe sepsis (severe life-threatening complication of an infection secondary because of an infection to an unstageable pressure ulcer. The note indicated Resident #121 was started on two antibiotics for the pressure ulcer infection. The history and physical also indicated Resident #121 was in an acute on chronic kidney failure condition related to the sepsis. The history and physical note indicated in the emergency room , Resident #121's sacral pressure ulcer was foul smelling, extensive, and positive for gases (gas produced by dying tissue). Record review of a Death Summary note, dated [DATE], indicated Resident #121 was treated with pain medication and anxiety medication and died peacefully in the night. The note indicated Resident #121 had intractable pain and the family agreed to make him a do not resuscitate and placed him on palliative care with the intent of discharging to a nursing facility with hospice care 2.) Record review of Resident #120's face sheet, dated [DATE], indicated he was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included bacterial peritonitis (infection of the peritoneal cavity), severe sepsis(severe complication of an infection) with septic shock, and an unstageable pressure ulcer of the sacral region. Record review of the admission-readmission assessment, dated [DATE], indicated Resident #120 had alterations in skin integrity. The assessment indicated he had a sacral pressure wound. The assessment had no measurements of Resident #120's wounds. Record review of a Braden Scale for Predicting Pressure Sore Risk, dated [DATE], indicated he was at risk for pressure injuries. Record review of an Initial Wound Evaluation and Management Summary, dated [DATE], indicated Resident #120 had a stage 4 pressure wound to the sacrum measuring 10 cm x 10 cm x 4 cm with 30% of the wound bed slough, 40% granulation tissue, and 30% muscle, facia, and/or bone. The wound care physician recommended off-loading of the wound, and to turn side to side every ,d+[DATE] hours, if able. The wound care note indicated the dressing treatment plan was Dakin's solution apply once daily, cover with abdominal pad. The wound care note indicated the wound care physician performed surgical removal of the devitalized tissue which included slough, biofilm, and no-viable periosteum and bone were removed at a depth of 4 cm. Record review of Resident #120's skin assessment dated [DATE], indicated he had a stage 4 sacral pressure ulcer measuring 10cm x 10cm x 4cm. During an observation on [DATE] at 11:09 a.m., Resident #120 was lying flat on his back on his bed, the wound vacuum was sitting in his wheelchair. Resident #120 said he had been at the facility for 5 days. During an observation and interview on [DATE] at 4:45 p.m., ADON A said Resident #120's wound vacuum would not seal well due to the proximity to Resident #120's colostomy bag. Resident #120 was lying flat on his back. Resident #120's body reached from side to side of the mattress. During an observation on [DATE] at 8:20 a.m., Resident #120 appeared to be taking up the entire mattress. The wound vacuum device was sitting in his wheelchair and not connected to Resident #120 abdomen. Resident #120 was lying on his back, and there was not a specialized mattress underneath Resident #120. Record review of Resident #120's electronic medical record indicated the Dietician recommendation of Juven 1 package twice daily was not implemented but another Arginaid (dietary supplement to enhance wound healing) one packet twice a day was ordered and implemented on [DATE]. Record review of the physician's orders, dated [DATE], indicated Resident #120 had an order received on [DATE] for the stage 4 sacral wound to cleanse wound with wound spray use barrier cream around the wound skin, apply ,d+[DATE] strength Dakin's-soaked gauze to wound base then cover with dry gauze and secure with abdominal pad, secure with foam tape, change daily, and as needed for saturation or dislodgement. Record review of the [DATE] EMR wound care entry for Resident #120's sacral wound indicated the wound care was not performed on [DATE], [DATE], [DATE], [DATE], and [DATE] according to the physician's orders dated [DATE]. During an interview on [DATE] at 10:00 a.m., the Wound Care Physician indicated he was unaware of Resident #121 not receiving wound care for 7 days after he provided orders on [DATE]. The Wound Care Physician indicated he would expect all residents who had a Stage 3 or Stage 4 pressure ulcer to have a low air loss mattress, and he was unaware Resident #120 had not had a low air loss mattress. The physician said he would expect the facility to set the low air loss mattress according to the resident's needs. During an interview on [DATE] at 10:15 a.m., LVN B said Resident #121 was admitted to the hospital yesterday ([DATE]) evening with a diagnosis of sepsis from the wound infection, and Resident #120 was admitted to the hospital for a wound infection not diagnosed yet with sepsis. During an interview on [DATE] at 10:30 a.m., ADON G said she was not wound care certified nor had she been certified by the wound care company to perform wound care in the facility. LVN G said she had not been checked off on wound care skills but was assigned to provide wound care. During an interview on [DATE] at 2:24 p.m., ADON A she indicated she had been doing wound care in the facility for three weeks. ADON A said she had been a nurse [AGE] years but had never treated wounds such as pressure injuries. ADON A said she had not had a check off completed since being assigned wound care. ADON A said ADON G made rounds with the wound care physician on Thursday mornings and ADON G put the wound care orders in the computer. ADON A said during the period of [DATE] to [DATE] ADON G was responsible for the wound care for Resident #121. ADON A said she made ADON G aware Resident #121's wound was declining. ADON A said she was unaware of Resident #121's low air loss mattress not being set according to his current weight. ADON A said there was not a monitoring system for checking the low air loss mattresses. ADON A said she had not called the Wound Care Physician, the resident's doctor, nor the medical director. ADON A said she was responsible for the wound care for Resident #120. ADON A said Resident #120 did not have a low air loss mattress because he required a bariatric low air loss, and the facility did not have this mattress available. ADON A said the DON was made aware, but she was informed the facility did not have a contract with a durable medical equipment supply company to obtain a bariatric low air loss mattress therefore Resident #120 remained on the standard hospital bed mattress. During an interview on [DATE] at 3:35 p.m., the DON said she had visualized Resident #121's sacral wound and remembered the wound to be very small when he admitted . The DON said she did not remember any orders for Resident #121's wound care other than the one's implemented on [DATE]. The DON said she was unaware Residents #120 and #121missed wound care treatments. The DON said she was responsible for the implementation of the dietary recommendations, and she said she must have missed the orders for Resident #121. The DON said she did make rounds and saw the resident's wounds with the ADONs, and at that time she would stage the wounds. The DON said she ran a report on Mondays to show missed treatments. The DON said with missed wound care a resident could develop an infection and the infection could lead to death. The DON said she was unaware wound treatments were missed. During an interview on [DATE] at 8:52 a.m., the Medical Director said he had not seen the sacral wounds for Residents #120 and #121. The Medical Director said he was not made aware of the missed wound care for Residents #120 and #121 sacral wounds. The Medical Director said missed treatments to stage 4 pressure injuries were not acceptable and could cause a decline in the wound. During an interview on [DATE] at 9:36 a.m., Resident #121's Physician's Nurse indicated the physician had not been notified of the missed stage 4 sacral wound decline nor the missed treatments to the sacral wound. The Physician's Nurse said the hospital communicated with her concerning the wound condition. The nurse said she was informed by the hospital Resident #121's received debridement to the sacral wound on [DATE] and during the surgical procedure he went into A-fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow) and now required 5 liters of oxygen. During an interview on [DATE] at 4:39 p.m., with the Interim Administrator said he would expect the nurses to input the wound care orders in on admission, expected the wounds to be measured, expected the treatments to be implemented. The Interim Administrator said not receiving wound care could cause a wound to have a serious decline. 45879 3. Record review of Resident #5's electronic face sheet, dated [DATE], revealed a [AGE] year old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included multiple sclerosis (a chronic, typically progressive disease involving damage to the sheaths of nerve cells in the brain and spinal cord, whose symptoms may include numbness, impairment of speech and of muscular coordination, blurred vision, and severe fatigue), sepsis (a serious condition resulting from the presence of harmful microorganisms in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death), anxiety (what we feel when we are worried, tense or afraid), high blood pressure, and Alzheimer's ( a type of dementia that affects memory, thinking and behavior). Record review of Resident #5's quarterly MDS assessment, with an ARD of [DATE], revealed under Section B, Hearing, Speech, and Vision, was coded as a 0 indicating she understands and was understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 14 which indicated the resident was cognitively intact. Section G, Function Status, under section B indicated she needed extensive assistance with bed mobility, personal hygiene, total assist with transfers, dressing, bathing, and supervision with eating. Section M, Skin Condition, under section M1200 she received pressure ulcer/injury care and application of nonsurgical dressing during the look back period. Record review of Resident #5's comprehensive person-centered care plan, dated initiated [DATE], and revised on [DATE]. revealed the Focus indicted: Resident #5 was at risk for further skin breakdown, also had a wound to right, distal, lateral calf lower leg and pressure area to right ischium related to immobility, incontinence, and disease process. Intervention indicated: Keep physician and RP informed of my progress. During observation and interview on [DATE] at 9:02 a.m., Resident #5 was in her bed with her heels not floated and lying flat on top of one pillow. There was no wedge present to float the heels and no pressure relieving boots present. Resident #5 said she did not know what heel protectors were, but she had not had the boots on in a while. She said normally her feet were elevated. Record review of Resident #5's skin assessment completed on [DATE], did not reveal the 4 new pressure areas to right and left foot. It did indicate: Left Ischium stage 4 measuring 1.0X0.5X0.5cm, Right Ischium stage 4 measuring 3.0X0.4X0.2cm, Sacrum stage 3 measuring 3.0X2.7X0.3 and right ankle stage 4 measuring 3.0X0.5X0.1cm. In the comment box it indicated; New unstageable areas to feet, we will be using skin prep daily. Record review of Resident #5's wound care notes, dated [DATE] indicated: Site1, Left Ischium stage 4 measuring 1.0X0.5X0.5cm, Site2, Right Ischium stage 4 measuring 3.0X1.0X0.2cm, Site3, right calf stage 4 measuring 3.0X0.5X0.1cm and Site 6, Sacrum stage 3 measuring 3.0X2.7X0.3cm. Record review of Resident #5's [NAME] notes, dated [DATE], indicated the above wounds and 2 new areas: Site 7, Unstageable DTI of the right foot measuring 3.0X1.0cm. Site 8, Unstageable DTI of the left foot measuring 3.0X2.0cm. It did not reveal 4 new areas on [DATE] only 2 new areas. Record review of Resident #5's physician orders., Apply heel protectors to feet while in bed. 1) Apply skin prep once daily to unstageable DTI (deep tissue injury) on outer aspect of right foot, 2) Apply skin prep once daily to unstageable blister to inner left foot arch, 3) Apply skin prep once daily to unstageable DTI on inner aspects of left foot,4) Apply skin prep once daily to unstageable blister to inner aspect of right foot. Record review of Resident #5's wound care note, dated [DATE], indicated the following: Site 1,Left Ischium stage 4 measuring 0.8X0.5X0.5cm, Site 2,Right Ischium stage 4 measuring 2.0X0.4X0.2cm, Site 3,right ankle stage 4 measuring 0.2X0.1X0.1cm,Site 6, Sacrum stage 3 measuring 3.0X2.7X0.cm, Site 7, Unstageable DTI of the right foot measuring 2.0X1.0cm Site 8, Unstageable DTI of the left foot measuring 3.0X2.0cm, Site 9, stage 2 pressure wound of left medial foot measuring 6.0X1.0X0.1cm, Site 10, unstageable ulcer on right foot with no measurements. Record review of Resident #5's treatment record, dated [DATE], indicated: the following treatment orders started [DATE]:. Apply skin prep once daily to unstageable blister to inner aspect of right foot. Apply skin prep once daily to unstageable DTI to outer aspect of right foot. Apply skin prep once daily to unstageable blister to inner left foot arch. Apply skin prep once daily to unstageable DTI on inner aspects of left foot. Record review of Resident #5's physicians orders dated [DATE] indicated an order for heel protectors to feet when in bed started on [DATE]. During an observation on [DATE] at 10:31 a.m., Resident #5 was observed in her bed watching television. Her heels were not floated and were lying flat on top of one pillow. There was no wedge present to float the heels and no pressure relieving boots present. During an observation and interview on [DATE] at 11:10 a.m., ADON G performed wound care on Resident #5, 4 dark purple areas which were not noted on the treatment sheet to left and right foot were observed. They presented as a deep tissue injury (DTI). The ADON G said those were identified last week on [DATE] on rounds with the Wound Care Doctor. ADON G said she forgot to add them last week on the treatment record because her computer was messed up. ADON G said without orders being on the treatment administration record (TAR), treatments could go untreated. During an observation on [DATE] at 12;25 p.m., ADON G measured Resident #5 other 2 new areas, presenting as DTI that were not on the [DATE] wound care notes, right side of foot at 2.0X2.0 cm and left inner top of foot at 3.0x2.0cm. During a phone interview on [DATE] at 9:24 a.m., Wound Care Doctor said Resident # 5 had 2 new identified areas to the right and left feet on today's rounds. He said they identified 2 other new areas to right and left feet last week on rounds but was not aware the treatment orders had not be implemented. The Wound Care Doctor said ADON G called him yesterday on [DATE] about the 2 new areas and orders were given. During an observation on [DATE] at 5:23 p.m., Resident #5 was in her bed with heels floated with a wedge underneath her lower legs but no pressure relieving boots were present. During an observation and interview on [DATE] at 2:57 p.m., Resident #5 was in her bed with heel protectors on, but they hung off her feet. Resident #5 feet and toes were touching the footboar [TRUNCATED]

Based on observation, interview, and record review, the facility failed to maintain acceptable parameters for nutritional status such as usual body weight or desirable body weight range by failing to provide nutritional and hydration care and services to residents consistent with the resident's comprehensive assessment for 4 of 21 Residents reviewed for weight loss. (Resident #'s 32, 38, 119, 220) 1.The facility did not address Resident #32's weight loss of 12.7-pounds in one month. 2.The facility failed to provide Resident #32 her magic cup (nutritional ice cream) with lunch and dinner meals. The facility failed to have the dietician to address Resident #32 weight loss. 3.The facility did not address Resident #38's weight loss of 35 pounds since admission on 11/18/2022. 4.The facility did not obtain an admission weight for Resident #119. The facility did not address Resident #119's weight loss of 30 pounds. 5.The facility failed to ensure Resident #220 received an accurate weight upon admission or within the two weeks following. 6. The facility failed to implement dietician recommendations timely for Resident #220. An Immediate Jeopardy (IJ) situation was identified on 01/13/2023 at 1:20 p.m. While the IJ was removed on 01/17/2022, the facility remained out of compliance at a scope of a pattern with the severity of potential for harm that was not immediate jeopardy, with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for decreased nutritional status, decline in health, serious illness, or hospitalization . Findings included: Record review of the CMS 672, dated 01/09/2023, indicated in Section G, other. F140 1 resident with unplanned significant weight loss/gain. 1). Record review of Resident #32's face sheet, dated 1/13/2023, indicated Resident #32 was a [AGE] year-old female who was admitted to the facility on [DATE] with the diagnosis diagnoses which included of stroke, pain, seizures, dysphagia (difficulty swallowing) and malnutrition (lack of nutrition). Record review of Resident #32's consolidated physician's orders dated 01/13/2023 indicated Resident #32 had a diet order of mechanical soft and nectar thickened fluids dated 02/05/2022, and a magic cup with lunch and dinner dated 09/06/2021. Record review of Resident #32's computerized weights indicated her weight was 153.8 pounds on 12/09/2022 and 141.1 pounds on 01/06/2023. Record review of a comprehensive care plan dated 04/08/2023 and revised on 05/03/2021 indicated Resident #32 required assistance with her ADLs including assistance with eating, with staff to feed Resident #32 if she was unable to complete the task. The care plan indicated Resident #32 was at risk for weight loss with the goal of maintaining her current level of weight through 02/16/2023. The interventions included monitor for signs of malnutrition, a weight every month, and report a loss or gain of more than 5%. The comprehensive care plan also indicated Resident #32 was receiving a therapeutic diet and was at risk for nutritional deficit. The goal was Resident #32 would consume adequate fluid and would consume 75% or more of the meals served with no associated weight loss through next review dated 04/08/2021. The interventions included administer snacks, and supplements as ordered, and provide a magic cup with lunch and dinner dated 07/07/2021. Record review of an Annual MDS dated [DATE] indicated Resident #32 was sometimes understood and sometimes understands, and Resident #32's BIMs score was 00 indicating severe cognitive impairment. The MDS indicated Resident #2 required total assistance of one staff with meals. The MDS in Section K indicated Resident #32 did not have a swallow disorder or signs of a swallowing disorder. Section K also indicated Resident #32's height was 70 inches, and her weight was 147 lbs. with no weight loss or weight gain documented. Record review of a weight record dated 01/13/2023 indicated Resident #32's 180 days prior was 151.8 pounds., 90 days prior weight was 152.8 pounds., and on 01/06/2023 Resident #32's weight was 141.1 pounds. Record review of the dietician reports revealed the following: -On *10/22/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *11/11/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *11/30/2022, there was: no mention of recommendations for weekly weights for Resident #32. -On *12/10/2022, there was: no mention of recommendations for weekly weights for Resident #32. - On *12/18/2022, there was: no mention of recommendation for weekly weights for Resident #32. On *01/08/2023 and 01/09/2023, there was: no mention of recommendations for weekly weights for, Resident #32. During observations on 01/10/2013 - through 01/11/2023 for Resident #32 revealed the following: -On *01/10/23 at 12:55 p.m., there was no supplement with the Resident #32's lunch meal. -On *01/10/2023 at 5:55 p.m., there was no magic cup with her Resident #32's evening tray. - On *01/11/2023 at 12:25 p.m., there was no magic cup with her Resident #32's lunch tray. -On *01/11/2023 at 6:00 p.m., there was no supplement with her Resident #32's evening tray. During an interview with the DON on 01/11/2023 at 3:26 p.m., The DON said she inputs the resident's weights in the computer after their weight was obtained. The DON said the person obtaining the weights just logs the weight obtained. The DON said when she reviews the weights, she stars them for a reweight to verify. The DON said the hospital weights were often not correct therefore it was important to have a weight. Record review of the undated dietary supplement list, there were no residents receiving a magic cup at lunch or dinner. 2) Record review of Resident #38's face sheet, dated 1/13/2023, indicated Resident #38 was an [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the diagnosis diagnoses which included of stroke, diabetes (too much sugar in the blood), chronic kidney disease (longstanding disease of the kidney), and muscle weakness. Record review of the consolidated physician orders dated 1/13/23 indicated Resident #38 did not have a diet ordered. Resident #38 had orders in a que including the diet order waiting for processing. Record review of Resident #38's comprehensive care plan dated 11/29/2022 there was no care plan addressing the risk of weight loss or actual weight loss. Record review of the clinical records for Resident #38 indicated the Initial MDS was not completed. Record review of Resident #38's weights indicated his weight on 11/18/2022 was 225 pounds, his weight on 11/29/2022 was 200 pounds, his weight on 12/17/2022 was 242 pounds, and on 01/06/2023 was 190 pounds. Record review of a dietician progress note dated 11/30/2022 indicated Resident #38 weight was 200.0 pounds with a height of 73 inches. The dietician's note indicated Resident #38 had a regular diet with thin liquids, he could feed himself with supervision. The goal of the recommendations was he would maintain weight without a significant change. And the recommendations were to continue the diet. Record review of a dietician's consultant, dated 11/30/2022, indicated Resident #38 had no recommendations even though the weights indicated he had already lost 25 pounds. Record review of a dietician's consultant report dated 12/10/2022 indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated 12/18/2022 indicated Resident #38 was not evaluated. Record review of a dietician's consultant report dated 01/08/2023 indicated Resident #38 was not evaluated. During an observation on 01/09/2023 at 1:05 p.m., Resident #38 was eating lunch in his room. Resident #38 remains on isolation precautions for C-diff, an infection causing profuse diarrhea. During an observation on 01/10/2023 at 1:15 p.m., Resident #38 was eating lunch while lying in his bed. Record review of a dietary profile dated 01/11/2023 indicated Resident #38 was receiving a regular diet with no dietary supplements. 3) Record review of a face sheet dated 01/11/2023 indicated Resident #119 was an [AGE] year-old female who admitted on [DATE] with the diagnoses of joint replacement surgery, muscle weakness, and high blood pressure. Record review of the Admission MDS dated [DATE] indicated Resident #119 understood others and she was understood. The MDS indicated Resident #119 had problems with recall and her BIMs score was an 11 indicating she had moderate impairment with cognition. The MDS indicated Resident #119 required extensive assistance of one staff member with eating. The section GG of the MDS indicated Resident #119 was independent eating with no assistance. The MDS indicated Resident #119 weight was 130 pounds in the section K0200. The MDS indicated Resident #119 had no weight loss or weight gain in the section of K0300. Record review of a hospital medication consolidation record dated 12/19/2022 indicated on 12/14/2022 Resident #119's weight was 160 pounds, and her height was 62 inches. Record review of a Dietary Profile dated 12/28/2022 indicated Resident #119 was receiving a regular diet and did not require any nutritional supplements. Record review of Resident #119's weights indicated only one weight was obtained since admission on 01/06/2023 of 130 pounds. Record review of a Dietician Progress Note dated 01/08/2023 indicated Resident #119 was eating 50-75 % of meals, her weight was 130 pounds and stable. The note also indicated Resident #119 had no skin issues. The notes comments indicated the diet was regular diet with thin liquids, to maintain weight without significant change over the next three months and to continue current diet. The dietician note does not indicate there was a significant weight loss from the hospital weight of 160 pounds and the facility weight of 130 pounds. Record review of the Dietician Recommendation indicated on 01/08/2023 Resident #119 had no recommendations. Record review of the comprehensive care plan dated 01/10/2023 indicated Resident #119 was receiving a regular diet with the goal of her weight remaining stable through the next review. The interventions included allow choices in food items, and provide snacks or supplements as ordered. During an observation on 01/10/2022 Resident #119 had consumed 50 % of her meal while in her bed. Record review of the consolidated physician's orders dated 01/11/2022 indicated Resident #119's diet was a regular diet with thin liquids started 12/19/22. 46310 4. Record review of Resident #220's face sheet, dated 1/13/23, revealed the resident was [AGE] year old male who admitted to the facility on [DATE] with diagnoses which included: chronic obstructive pulmonary disease (a chronic inflammatory lung disease that causes obstructed airflow from the lungs), sepsis (the body's extreme response to an infection), Type 2 diabetes mellitus without complications (an impairment in the way the body regulates and uses sugar (glucose) as a fuel), peroration of intestine (a loss of continuity of the bowel wall), paroxysmal atrial fibrillation (terminates spontaneously or with intervention within seven days of onset), heart failure (a condition that develops when your heart doesn't pump enough blood for your body's needs), and acute cystitis without hematuria (a sudden inflammation of the urinary bladder). Record review of Resident #220's Quarterly MDS assessment was not completed and was not due according to admitted . Record review was attempted of Resident #220's baseline care plan but one was not completed. No comprehensive care plan was due according to admitted . Record review of Dietary consult visit dated, 1/8/23, for updated nutritional assessments. It was recommended that Resident #220 his tube feeding, Glucerna, be increased 650 ML per hour from 500 ML per hour, as prescribed on discharge summary, and water increased to 35 ML per hour from 20ML per hour, as prescribed on discharge summary. Dietician requested accurate height and weight be completed as none was available. Record review of hospital discharge documents dated 12/29/22 indicated Resident #220 weighted 90.5 Kg (199.52 pounds) on 12/29/22, date of discharged . Record review of weight check on 1/11/23 indicated Resident #220 weighed 164.8 for a total weight loss of 34.3 (17.40 percent). This showed significant weight loss in less than a 30-day period . During observation on 1/9/23 at 5:45 p.m., Resident #220 was asleep in his bed. The head of the bed was elevated, and he was receiving his tube feeding via pump . The pump read 500 ML per hour of Glucerna and 20ML per hour of water. During observation of weight check for Resident #220 on 1/11/23, CNA S conducted an in-bed weight and the scale indicated, 164.8. During observation and interview on 1/11/23 at 09:49 AM with Resident #220, he said he was new the facility and was just placed back on the regular floor. He said he contracted COVID-19. He said he had not been weighed when he arrived. He said he was weighed, maybe a day ago. He said he was unsure if he has lost any weight. He said he received his food through tube feeding placed while in the hospital prior to his admission. He said he has not seen anyone that said they was a dietician or nutritionist. During observation of weight check for Resident #220 on 1/13/23, CNA S conducted an in-bed weight and the scale indicated, 162.4. During interview on 1/13/23 at 3:57 PM with CNA S, she said the DON usually had her to complete the weights weekly or monthly for residents. She said she knew she had to weigh new admits four times weekly and then it depended on if they have had any issues if she had to continue. She said she must weigh all residents at the beginning of the month. She said the weights must be done before the dietitian visits for the month. She said when she completed all the weights, she gave them to the DON, and usually within the next few days she would ask her to re-weigh a resident if needed. She said the DON entered all the weights into the electronic medical records, to her knowledge, after they have been reviewed and corrected. During an interview on 01/12/2023 at 2:24 p.m., the ADON A indicated there were no weekly standards of care meetings to review each resident with wounds, weight loss, or accidents. During an interview on 01/17/2023 at 1:36 p.m., LVN L indicated residents should be weighed on admission. LVN L indicated with not knowing the admission weight there could be a weight loss leading to skin problems, and even the loss of mobility. During an interview on 01/17/2023 at 2:39 p.m., the Regional Nurse Consultant indicated she was unaware of weight loss issues. The corporate nurse indicated new admissions should have a weight once a week for 4 weeks or until stable. The corporate nurse indicated the admitting nurse was responsible for obtaining the admission weight. The corporate nurse indicated there was not a reason for the admission or weekly weights not being obtained. During an interview on 01/17/2023 at 4:55 p.m., the Interim Administrator indicated the physician should be notified when the resident's weight falls in the parameter areas either a loss or a gain. The Interim Administrator indicated health issues could arise when weights were not monitored. The Interim Administrator indicated the charge nurses, and DON were responsible for the monitoring of weights. Record review of a Nutritional Management policy dated 07/01/2022 indicated the facility provides care and services to each resident to ensure the residents maintains acceptable parameters of nutritional status in the context of his or her overall condition. 2. Identification/Assessment: a. Nursing staff shall obtain the resident's height and weight upon admission, and subsequently in accordance with facility policy. C. A comprehensive nutritional assessment will be completed by a dietician within 72 hours of admission, annually, and upon significant change in condition. Follow-up assessments will be completed as needed. Record review of a Weight Monitoring policy dated 07/01/2022 indicated based on the resident's comprehensive assessment, the facility will ensure that all residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise. Compliance Guidelines: Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss may indicate a nutritional problem. 5. A weight monitoring schedule will be developed upon admission for all residents: A. Weights should be recorded at the time obtained. B. newly admitted residents-monitor weight weekly for 4 weeks, Residents with weight loss -monitor weight weekly. 6. Weight analysis: The newly recorded resident weight should be compared to the previous recorded weight. A significant change in weight is defined as: a. 5% change in one month, b. 7.5% change in 3 months, c. 10% change in 6 months. Documentation: a. The physician should be informed of a significant change in weight and may order nutritional interventions. These were determined to be an Immediate Jeopardy (IJ) on 01/13/2023 at 1:20 p.m. The Administrator was notified on 01/13/2023 at 1:20 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The Administrator was provided with the IJ template The IJ template was provided on 01/13/2023 at 1:25 p.m. The following Plan of Removal submitted by the facility. The plan of removal for F692 was accepted on 01/15/2023 at 5:16 p.m. and included the following: Weight: Residents at the care center reweighed to compare to January weights by DON, ADON, and transportation aide completed 01/14/2023: verified by record review of weekly weight logs. Any significant increase or decrease in weight addressed by notifying MD, dietician, and family. DON made notifications completed by 01/14/2023; verified by record review of resident printed orders. Any identified increase or decrease in weight was placed on weekly weights x 4 weeks and or until weight has been stabilized or until MD orders discontinue. Completed on 01/14/2023: verified by record review of the weekly weight log. Any new orders implemented immediately by licensed care staff. Completed 01/14/2023: verified by record review of the printed physician's orders. Admitting nurse or CNA will obtain admission weights with follow up by the ADON within 24 hours. Admission will have weekly weights x 4 weeks or until stable weights. Monitoring by DON, ADON, and MDS to prevent further systemic failure. Record review of weekly weight variance record dated 1/14/23 indicated 19 residents had weight variances identified. Record review of the physician orders indicated the physician had implemented supplements, dietician referrals, and weekly weight monitoring. Record review of in-service training report dated 1/12/23 indicated to implement all orders in a timely manner. 1. Dietary, Wound consultant treatments, and any other orders must implemented in a timely manner. 2. Orders must coincide with treatment and carried out as ordered. Interviews on 01/17/23 from 5:00 p.m. until 5:48 p.m. the surveyor confirmed the facility implemented their plan of removal. Interviews with 3 (6am-6pm) nurses LVN B, LVN D and LVN R, 2 (6pm-6am) nurses LVN U and LVN HH ,said they were in-serviced on obtaining weights on admission then every week for 4 weeks or stable, reporting weight changes to the physician. Interviews with 4 CNAs (6am-6pm) CNA FF, CNA GG, CNA D, and 4 CNAs (6pm-6am) CNA MM, CNA OO, CNA PP and CNA LL indicated they were in-serviced on obtaining weights on admission. The CEO and interim Administrator were informed the Immediate Jeopardy was removed on 01/17/23 at 6:16 p.m. The facility remained out of compliance at a severity level of potential for harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of 3 of 20 residents reviewed for laboratory services. (Resident # 44, Resident #35, and Resident #34) The facility failed to draw PT/INR (A prothrombin time (PT) test measures how long it takes for a clot to form in a blood sample. An INR (international normalized ratio) is a type of calculation based on PT test results) level for medication Coumadin (is a blood-thinning medicine that's used to treat and prevent dangerous blood clots) for Resident # 44 as ordered monthly for five months. The facility failed to draw routine hemoglobin A1C (HBA1C) (a blood test that shows what your average blood sugar (glucose) level was over the past two to three months) for Resident #35. The facility failed to obtain Resident #34's Vancomycin (is used to treat infections caused by bacteria. It works by killing bacteria or preventing their growth) trough level (is drawn immediately before the next dose of the drug is administered because it is the lowest concentration in the patient's bloodstream) as ordered prior to administration of first dose of Vancomycin. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 12:05 p.m. on 01/13/23. While the IJ was removed on 01/18/23, the facility remained out of compliance at the severity of no actual harm that is not immediate jeopardy with a scope identified as pattern due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of not having their medications at a therapeutic level, delays in treatment, and/or deterioration in condition. Findings included: 1. Review of Resident #44's electronic face sheet dated 01/13/23 revealed he was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses of high blood pressure, seizures, stroke, and anemia (low blood). Review of Resident #44's quarterly MDS assessment dated [DATE] revealed under Section B, Hearing, Speech, and Vision, he was coded as 2 for sometimes understands and sometimes understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 99 for severely impaired cognition. Section G, Function Status under section B indicated he needed total assist with dressing, personal hygiene, and extensive assist with bed mobility, transfers, eating and toileting. Section N, Medication, under section N0410 indicated Resident #44 received 7 days of Coumadin during the look back period. Review of Resident #44's physicians orders dated 1/13/22 revealed PT/INR to be drawn every 30 days for diagnosis of prostatic heart value (are designed to replicate the function of native valves by maintaining unidirectional blood flow). Review of Resident #44's comprehensive person-centered care plan dated 01/13/21 when it was initiated, and it was revised on 01/14/21. Focus indicated: Resident #44 had the potential for alteration in bleeding tendencies and increased bruising related to anticoagulants therapy of Coumadin. Interventions indicated: Administer medication as ordered, monitor for side effects and report ill findings to physicians. Review of Resident #44's labs did not reveal any PT/INR labs since 07/13/22 which was ordered monthly. During an interview on 01/12/23 at 5:37 p.m., LVN C said Resident #44 was on Coumadin and should be getting monthly Coumadin levels and failure to get labs could result in bleeding. During an interview on 01/12/23 at 5:46 p.m., LVN R said when charge nurses received new lab orders, they filled out a lab requisition and placed it in the lab book. LVN R said charge nurses then placed on the 24-hour report book to follow up on labs. LVN R said Resident #44 took Coumadin and thought he had a recent lab result. LVN R called the lab company to verify the last PT/INR and they confirmed his last results were PT-31.2 indicating high and INR-2.7 indicating high drawn on 07/13/22. LVN R said failure to do labs as ordered with Coumadin could cause Resident #44 to bleed out. During an interview on 01/12/23 at 5:50 p.m., the DON said she was aware Resident #44 did not have his Coumadin level drawn monthly as ordered. The DON said Resident #44's last coumadin level was last drawn on 07/13/22. The DON said it took time to get things in order and she was still working on this process. The DON said she did not have a system in place to monitor labs at this time During an interview on 01/12/23 at 6:10 p.m., the RNC said she was unaware Resident # 44 did not have a current PT/INR level but would make sure he got one done. The RNC said it is important to have the PT/INR drawn as ordered to ensure residents are in therapeutic levels and failure to do labs could cause bleeding. During a phone interview on 01/13/23 at 8:40 a.m., the Primary doctor said he was not aware PT/INR levels had not been drawn since 07/13/22. The Primary doctor said the facility should have drawn the PT/INR level as ordered. The Primary doctor said failure to draw PT/INR levels could lead to Resident #44 bleeding and having another stroke. Record review of Resident #44's progress note dated 01/13/2023 at 5:28 p.m., revealed PT/INR lab results received, PT 17.1, (normal range=9.0-12.2) and INR 1.4 (normal range 0.8-1.1). Physician made aware, new order to discontinue Coumadin 7.5mg and begin Coumadin 10 mg, give 1 tablet by mouth daily. Attempted to notify daughter to make aware of changes, call went unanswered. Resident #44 made aware of new change. Coumadin 10mg administered at this time, and new order to recheck PT/INR in one week. 2. Record review of a face sheet dated 01/17/23 indicated Resident #34 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cellulitis (bacterial skin infection that causes redness, swelling, and pain to the affected area), Chronic obstructive pulmonary disease with acute exacerbation (group of lung diseases that cause airflow blockage and breathing related problems), acute systolic congestive heart failure (left ventricle of heart becomes weak), and weakness. Record review of the quarterly MDS dated [DATE] indicated Resident #34 was usually understood and understood others. The MDS revealed Resident #34 had a BIMS score of 13 indicating intact cognition. The MDS indicated Resident #34 required extensive assistance with bed mobility, toileting, and personal hygiene. Resident #34 was totally dependent on dressing and bating. The MDS under section O, special treatments, procedures, and programs, had IV medications checked indicating Resident #34 had received IV medications within the last 14 days. Record review of Resident #34's comprehensive care plan did not indicate Resident #34 was receiving IV antibiotics. Record review of the order summary report dated 01/17/23 indicated Resident #34 had an order for Vancomycin HCL intravenous solution 750-0.9mg/150mls-% Use 150ml intravenously every 12 hours for cellulitis to right hand for 10 days with an order start date of 01/16/23. Record review of the hospital patient discharge summary report dated 01/15/23 indicated new medications to start included Vancomycin HCL injection 750mg/sodium chloride 0.9% bag 250ml take IV piggyback every 12 hours. 250ml/hr. *Hold dose and DO NOT administer IF Trough is 20 or higher. Get trough level before 1st dose on 01/16/23. Record review of the lab request form dated 01/16/23 indicated Vancomycin trough to be collected on 01/18/23. During an interview on 01/17/23 at 09:45 AM, Resident #34 said he received his first dose of IV medication last night. During an interview on 01/17/23 at 09:50 AM, LVN L said Resident #34 received his first dose of Vancomycin last night and was unsure if the vancomycin trough was obtained prior to Resident #34's first dose of vancomycin. During an interview on 01/17/23 at 12:51 PM, ADON A said she did not see the order to obtain a trough level before the first dose of vancomycin for Resident #34 and it was not obtained. ADON A said by not obtaining the vancomycin trough level, Resident #34 could be at risk for receiving more than the therapeutic dose of vancomycin. During an interview on 01/17/23 at 1:57 PM, the RNC said they should have obtained a vancomycin trough level prior administering the first dose of vancomycin. The RNC said by not obtaining the trough level as ordered the resident was a risk for receiving the wrong dose of vancomycin. The RNC said the nurse who hung the medication was responsible for ensuring Resident #34 had a vancomycin trough level prior to receiving his first dose of vancomycin. During an interview on 01/17/23 at 5:00 PM, the Interim Administrator said he expected the nurses to follow the physician orders. The Interim Administrator said by not following the physicians' orders could cause the resident to have adverse effect. Record review of the facility's policy titled Diagnostic Testing Services dated 07/01/22 indicated . this facility will provide the appropriate diagnostic services (laboratory and radiology) required maintain the overall health of its residents and in accordance with state and federal guidelines . 3. Record review of Resident #35's electronic face sheet, dated 01/13/23, revealed an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Metabolic encephalopathy (is a problem in the brain. It is caused by a chemical imbalance in the blood), diabetes, high blood pressure, Chronic obstructive pulmonary disease (COPD) (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs), and dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). Record review of Resident #35's quarterly MDS assessment, with an ARD of 10/07/22, revealed under Section B, Hearing, Speech, and Vision, she was coded as 1 for usually understand and usually understood by others. Section C, Cognitive Patterns, under section C0500 Brief Interview for Mental Status, which indicated a score of 10, which indicated moderately impaired cognition. Section G, Function Status, under section G0110 indicated she needed supervision with bed mobility, transfers dressing, eating, personal hygiene and toileting. Review of Resident #35's physicians orders revealed, HGBA1C every 6 months in March and September. Review of Resident #35's comprehensive person-centered care plan dated 03/30/18 when it was initiated, and it was revised on 11/08/22. Focus indicated: Resident #35 has the potential for complications related to diagnosis of Diabetes Melilites. Intervention: HBGA1c every 6 months, administer medication as ordered by physician and monitor for side effects. During an interview on 01/12/23 at 5:46 p.m., LVN R said when charge nurses receive new lab orders, they fill out a lab requisition and place in lab book. LVN R said charge nurses then place on 24-hour report book to follow up on labs. LVN R verified order for Resident #35's HGBA1C to be drawn in March and September. LVN R said failure to do this lab as ordered could lead to Resident #35 not receiving correct dose of medication. During an interview on 1/17/23 at 2:06 p.m., the RNC said all labs should be drawn as ordered. RNC said the charge nurses are responsible to ensure orders are received and lab requisitions are filled out completely. The RNC said administrative nurses was to follow up on all labs. The RNC said without labs been drawn as ordered, doctors would not know if the residents were within a therapeutic range. During an interview on 01/17/23 at 2:25 p.m., ADON D said she expected the charge nurses to fill out the lab requisition and to make sure it was done. ADON D said she expected the charge nurses once lab received back to notify the physician because writing faxed on paper does not tell us anything. ADON D said the ADON's should be following up on labs. ADON D said Resident #44 could bleed out without propre dose of medication. ADON D said Resident #35's oral, or insulin medication could need readjustment but without proper lab they could not detect therapeutic levels and could lead to organ failure. During an interview on 01/17/23 at 6:00 p.m., ADON D said Resident # 35 did not get her HGBAIC in September as ordered. ADON D said she was unaware why Resident #35 HGBA1C was not done. ADON D said with the new lab system, hopefully no more labs will be missed. The Administrator was notified 01/13/22 at 1:20 p.m. that an Immediate Jeopardy (IJ) was identified due to the above failures. The IJ template was provided on 01/13/22 at 1:25 p.m. and a Plan of Removal (POR) was requested. The following Plan of Removal submitted by the facility was accepted on 01/15/23 at 5:00 p.m. and included the following: 1. Resident has received lab draw on 01/12/23. 2. All resident on anticoagulant identified, only one identified. Identified by report and database confirming any resident on anticoagulant. Every monthly order in DCOL lab binder. Completed 01/13/23. 3. MD notified of any residents without current PT/INR. Zero identify. Completed 1/13/23 4. Order for new PT/INR to be immediately and lab notified. Completed 01/13/23 5. Families made aware. Completed 01/13/23 6. Orders for routine lab draws for anticoagulants current and corrected. DON insured lab and orders corrected. Completed 01/13/23. 7. In-serviced all nursing staff of all residents on anticoagulants and routine lab orders. In-service completed by DON. In-service included anticoagulants and monitoring. In-service included how to run anticoagulant report from PCC. Completed 01/13/23 Monitoring: Interviews on 01/17/23 from 5:00 p.m. until 5:48 p.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interviews with 3-6am-6pm (LVN KK, LVN R and ADON G and 2-6pm-6am (LVN OO and LVN M) nurses who indicated they had received a written in-service regarding monitoring of labs. What blood thinners are such as medicines that prevent blood clots from forming. Residents who may needs blood thinners, with a certain heart or blood vessel diseases or an abnormal heart rhythm called atrial fibrillation. The different types of blood thinners which are anticoagulants, such as heparin or Coumadin, because they slow down your body's process of making clots and antiplatelets, such as aspirin and clopidogrel, which prevent blood cells called platelets from clumping together to form a clot. How to take blood thinners safely by getting labs to ensure you're taking enough medicine to prevent clots, but not so much that it causes bleeding; and the side effects of blood thinners was bleeding. All the nurses above stated they knew how to run a report to check to ensure any resident on Coumadin had an order for PT/INR. Record review of an in-service training report dated 1/13/23 indicated anticoagulants and monitoring were the topic of the in-service. The training session included: What are blood thinners? Blood thinners are medicines that prevent blood clots from forming. They do not break up clots that you already have. But they can stop those clots from getting bigger. It's important to treat blood clots, because clots in your blood vessels and heart can cause heart attacks, strokes, and blockages. Who needs blood thinners? You may need a blood thinner if you have: Certain heart or blood vessel diseases An abnormal heart rhythm called atrial fibrillation A heart valve replacement A risk of blood clots after surgery Congenital heart defects What are the different types of blood thinners? There are different types of blood thinners: Anticoagulants, such as heparin or warfarin (also called Coumadin), slow down your body's process of making clots. Antiplatelets, such as aspirin and clopidogrel, prevent blood cells called platelets from clumping together to form a clot. Antiplatelets are mainly taken by people who have had a heart attack or stroke. How can I take blood thinners safely? When you take a blood thinner, follow the directions carefully. Blood thinners may interact with certain foods, medicines, vitamins, and alcohol. Make sure that your health care provider knows all of the medicines and supplements you are using. You may need regular blood tests to check how well your blood is clotting. It is important to make sure that you're taking enough medicine to prevent clots, but not so much that it causes bleeding. What are the side effects of blood thinners? Bleeding is the most common side effect of blood thinners. They can also cause an upset stomach, nausea, and diarrhea. Other possible side effects can depend on which type of blood thinner that you are taking. Call your provider if you have any sign of serious bleeding, such as: Menstrual bleeding that is much heavier than normal Red or brown urine Bowel movements that are red or black Bleeding from the gums or nose that does not stop quickly Vomit that is brown or bright red Coughing up something red Severe pain, such as a headache or stomachache Unusual bruising A cut that does not stop bleeding A serious fall or bump on the head Dizziness or weakness ANTICOAGULANT MONITORING Keywords: Oral anticoagulant therapy TYPES OF ANTICOAGULANT APPROPRIATE TESTS See also Thrombolytic therapy (Thrombolysis). The type of tests and frequency of testing depends on the anticoagulant therapy and indication, as well as clinical history. Heparin (standard, unfractionated) Prior to commencing Full blood count (including platelet count), Coagulation profile (including APTT, INR, Prothrombin time). Platelet count is recommended on day 5 post commencement of therapy. The method for monitoring continuous IV heparin infusion is usually APTT, however Activated clotting time (ACT) and Anti factor Xa are also used. The level of anticoagulation may be monitored with the APTT and/or Anti factor Xa level, however monitoring(including the test and frequency) should be according to local guidelines. Prophylactic (low dose) heparin does not usually require monitoring. In the event of bleeding on heparin, urgent APTT and Full blood count should be performed. If progression of thrombosis, or thrombosis in other site(s) while patient on heparin, causes include: Inadequate anticoagulation Heparin-induced thrombocytopenia (HIT type II) Antithrombin deficiency APTT, Anti factor Xa See also Heparin-induced thrombocytopenia investigation Antithrombin - ideally should be deferred until heparin has been ceased (if not performed for some reason prior to heparin therapy), since heparin will reduce the measured level. Consultation with a haematologist is recommended to guide further testing and management. See also Thrombosis - venous. Low molecular weight heparin (LMWH) and heparinoids Prior to commencing, Full blood count (including platelet count), Coagulation profile (including APTT, INR, Prothrombin time) and renal function should be performed. Platelet count is recommended on day 5 post commencement of therapy. Monitoring of (full dose) low molecular weight heparin (LMWH) therapy is not generally required, except in renal failure, extremes of body weight, pregnancy or other situations where there is an increased risk of bleeding. LMWH should be used with care and monitoring in patients with any abnormality of renal function, particularly the elderly. Monitoring is with an Anti factor Xa level, but should be done in consultation with a haematologist and according to local guidelines. Monitoring of routine LMWH prophylaxis is not cost effective, is not required to achieve clinical efficacy and is not indicated to predict risk of bleeding, which is minimal with prophylactic doses in patients with normal renal function. Oral anticoagulants Warfarin (Marevan/Coumadin) Prothrombin time, INR Increased frequency of testing may be required following change in dose, change in diet/oral intake, intercurrent illness and change in concomitant medications (including antibiotics). For information on reversal of warfarin, see guidelines below. New oral anticoagulants (NOACS) NOAC do not require monitoring when used for thromboprophylaxis or therapeutic anticoagulation. However, the anticoagulant effect should be measured if: 1. Clinically significant bleeding occurs 2. There is a change in clinical circumstances (eg, urgent surgery is required) Routine coagulation studies may (but sometimes do not) provide information about the presence of anticoagulant effect (see below). Specific assays for quantitation of drug levels may or may not be available depending on the drug and laboratory. Due to the short half-life of these drugs, information on the time of the last dose is important in interpreting the results. Refer to coagulation laboratory. Dabigatran The Thrombin time (TT) is the most sensitive routine coagulation assay to detect the presence of dabigatran. A normal TT excludes the presence of dabigatran, however low drug levels may significantly prolong the TT, therefore the assay cannot be used to estimate plasma levels. Some laboratories may perform a drug level assay (dilute thrombin clotting time assay). Rivaroxaban The Prothrombin time, INR (using a thromboplastin that is sensitive to rivaroxaban) is the most sensitive routine coagulation assay, however a normal PT does not exclude its presence. The APTT and PT cannot estimate the intensity of anticoagulant effect Some laboratories may provide a drug specific anti-Xa for quantitative assessement of drug plasma levels. The clinical relevance of drug plasma levels is not known, and therefore should not be used to inform drug doses. Apixaban A normal PT and APTT does not exclude significant anticoagulant effect. Drug specific anti-Xa assay may be used to estimate drug plasma levels, but this is not yet widely available. Please consult with laboratory. References: Garcia DA et al; American College of Chest Physicians. Parenteral anticoagulants: Antithrombotic Therapy and Prevention of Thrombosis. 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141 (2 Suppl): e24S-43S. [NAME] H et al. An update of consensus guidelines for warfarin reversal. MJA 2013; 198: 198-199. [NAME] H et al. New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. IMJ 2014; 44: 525-536. Record review of a written in-service dated 01/15/23 indicated licensed staff had been educated on labs. The CEO and interim Administrator were informed the Immediate Jeopardy was removed on 01/18/23; however, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy and a scope of pattern due to the facility's need to evaluate the effectiveness of the corrective systems. 46928 Record review of the original in-service conducted with all nursing staff addressed the policy for all residents with lab orders. The in-service included lab and diagnostic test result protocol. Monitoring to be completed by DON, and ADONs. In-service completed by the DON on 01/13/2023; verified by interview of in-serviced material. After re-entering the facility on 2/8/23 at 9:05 a.m. additional information was gathered and included the following interviews and record reviews: Record review of the laboratory process effective 01/18/23 indicated: *Admission orders were reviewed during next the clinical meeting. *All orders were checked to ensure they were entered correctly. Any unclear orders were clarified. *Any laboratory orders were verified of placement in the EMR to ensure laboratory requisitions were completed in the laboratory requisition book. *Nursing to monitor laboratory results and review to ensure the MD was aware. Any new orders received would be implemented. *Clinical meetings will occur twice a day to ensure communication was followed and any changes were updated. *Initial requisition would indicate if a resident had recurring laboratory orders. *During the daily clinical meeting, the PCC dashboard will be utilized to monitor for lab results, MD review, and followed for any order changes. Interviews on 02/08/23 from 09:51 a.m. until 11:05 a.m., the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Interview with 3- 6am-6pm (LVN B, LVN R and LVN Y) nurses who indicated the laboratory process included: when an order for a laboratory was obtained, the order was placed in the resident's electronic medical record, the laboratory requisition was filled out, placed in the laboratory book, and was written on the 24hr report. Residents with standing laboratory orders were indicated on the lab requisition form. The three LVNs said the ADONs review the lab book daily. Interview with ADON A, ADON G, and RNC indicated they had placed a laboratory monitoring process on 1/18/23. New orders and admission orders were reviewed during the next clinical meeting. The laboratory process was: -Laboratory orders received were ensured they were entered corrected in the EMR. -The laboratory requisition was completed. -The laboratory requisition was placed in the laboratory book. The laboratory book was checked daily by the ADONs. Nursing would monitor for laboratory results, notify medical director, and implement any new orders received. If a laboratory result had not been received by 3:00 p.m., the ADON would then call the laboratory to check on the results. Record review of 6 of 6 new admissions revealed if they had orders for laboratory services the laboratory levels were obtained according to orders. Record review of 2 of 2 resident receiving vancomycin had their vancomycin troughs completed as ordered. Record review of 4 of 4 residents reviewed for monthly laboratory orders were on the monthly laboratory log to be obtained. Record review of Resident #34's vancomycin trough level, collected on 01/18/23, was 12.1. The medical director had reviewed and signed the laboratory results which included orders to discontinue the vancomycin due to the resident's refusal. Record review of Resident #44's PT/INR results indicated his INR was 2.8. Resident #44 was to have his INR rechecked on 02/20/23. Resident #44 was on the scheduled monthly laboratory log. The administrator was notified on 2/8/23 at 7:25 p.m. the immediacy remained in place until 1/18/23.

Based on interviews and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents reviewed for wound treatment. (Resident #1). 1. The facility failed to provide care for Resident #1's wounds as identified on the resident's physician's orders. Resident #1 was admitted to the hospital due bilateral leg infection. Resident #1 and family reported wound care was not provided consistently. Per record review, Resident #1 reported she did not receive appropriate care and her wounds had gotten worse which led to her inability to ambulate when she was admitted to the hospital. 2. Wound care administration of treatment was not recorded as ordered by the physician for Resident #1. This failure could place residents all residents at risk for a failure to improve and/or attain their highest practicable physical, mental, and/or psychosocial well-being. Findings included: Review of Resident #1's Face Sheet, revealed Resident #1 was a [AGE] year old female admitted on [DATE] and transferred to the hospital on 1/4/2023 with diagnoses including: intrahepatic bile duct carcinoma (bile duct cancer), muscle weakness (generalized), other lack of coordination, weakness, difficulty in walking, localized edema, hypertension, acute cystitis with hematuria, essential primary hypertension, gout, COVID-19 12/16/2022, cellulitis of right lower limb, cellulitis of left lower limb, and unspecified jaundice. Review of Resident #1's Care Plan, dated 12/19/2022, revealed no risks or interventions for skin integrity concerns. Review of Resident #1's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) Score of 13. Record review of Resident #1's Wound Evaluation and Management Summaries, dated 12/15/2022 and 12/29/2022, revealed arterial wound of the left leg (Site 1) had increased in size from 15 x 14 x 0.1 cm to 18 x 14 x 1 cm, surface area increased from 210 cm^2 to 252 cm^2, and exudate (drainage) increased from none to light serous. Arterial wound of right leg (Site 2) revealed wound size increased from 20 x 16 x 0.1 cm to 20 x 18 x 0.5 cm, surface area increased from 320.00 cm^2 to 360.00 cm^2. Wounds to arterial left and right leg had 90% thick adherent black necrotic tissue (eschar), with deteriorated wound progress on 12/29/2022. Dressing treatment plan included to apply abdominal pad apply once daily for 16 days, sodium hypochlorite solution once daily for 30 days, and secondary dressing to be applied once daily for 16 days. Post operative recommendations and updates to the plan of care were documented in the assessment and plan section. Summarization of wound care assessment and individualized treatment plan for site 1 and site 2 of the left and right leg revealed wounds deteriorated due to generalized decline of patient. Review of Resident #1's Progress Notes, dated 01/04/2023, written by LVN A revealed the following: Resident had a 101.2 temperature with confusion. Wound care noted with increased warmth and pain noted. Bilateral lower extremity (leg, ankle, and foot) noted to be warm to touch and with edema. New order received to transfer resident to the hospital for further evaluation. Review of Resident #1's Progress Notes, dated 12/19/2022, written by LVN B revealed: Resident is awake, alert, oriented x 3, skin warm & dry to touch, respirations unlabored, abdomen soft, bowel sounds present x 4, resident is bed bound, incontinent of bowel & bladder. Turned Q (every) 2 hours & prn (as needed). Antibiotic therapy ongoing, with no adverse reactions noted. Diet tolerated without problems, voiding quantity sufficient. Bilateral lower extremities observed with dressings intact, gauze stained with serosanguinous drainage, to be changed every other day, Normal saline, xeroform gauze, & kerlix utilized for dressing change on 12/18/22 . Review of Resident #1's Treatment Administration Record (TAR), from December 2022 through January 2023, revealed the following: *Physician Order, start date of 12/13/2022, for wound treatment to Bilateral Lower Extremity (leg, ankle, and foot), .every day shift every other day for Wound healing. No administration of treatment was recorded on 12/17/2022 through 12/23/2022 as ordered by the physician. *Physician Orders, start date of 12/12/2022, for wound treatment to left inner thigh and sacrum, .daily and PRN (as needed) every day shift for Wound healing. No administration of treatment was recorded on 12/14/2022 through 12/17/2022, 12/19/2022, 12/21/2022, and 12/23/2022 through 12/24/2022 as ordered by the physician. *Physician Order, start date of 12/30/2022, for arterial wounds to right and left leg, sacrum, and left inner thigh treatments to be conducted every day shift. No administration of treatment was recorded for 1/2/2023 as ordered by the physician. Review of Resident #1's Hospital Records, dated 1/4/2023, revealed the following history of present illness: XXX[AGE] year-old female with medical history of unresectable intrahepatic primary biliary tract cancer, chronic lower extremity edema/wound secondary to chemotherapy, osteoporosis, iron deficiency anemia who initially presented to ED from nursing home with chief complaint of worsening bilateral lower extremity wound leading to inability to ambulate today. Patient reports chronic lower extremity edema/swelling secondary to chemotherapy initially started a few months ago. Patient has been staying tin the nursing home for the past few weeks for assistance with wound care. However, patient stated that she has not been receiving appropriate care from a nursing home and her wound has been worsening. Review of Resident #1's Hospital Records, dated 1/4/2023, revealed the following X-ray report: Lower extremity left with contrast: Bilateral leg infections with wounds starting in medial thigh and extending down to toes . Cortical screw from prior surgery is also at the first metatarsal head. Involving a length of 14.5 cm over the lower leg, beginning at the mid tibial shaft and extending inferiorly, there is prominent skin defect with irregular sheet like gas collection in the superficial subcutaneous tissues involving the anterior and lateral aspect of the lower leg. There was no direct extension into the underlying muscular bundles. No fluid expansion of the muscles. No focal abscess cavity was evident. Osseous structures were intact. No aggressive osseous destruction. Prominent edema of the subcutaneous tissues of the foot also evident without soft tissue gas. Extensive ulceration of the subcutaneous tissues of the lower leg without invasion of the underlying muscle or bone. No drainable abscess is evident. Review of Resident #1's Hospital Records, dated 1/4/2023, revealed the following X-ray report: Lower extremity right with contrast: bilateral leg infections. Extensive subcutaneous gas/cellulitis involving the lower leg. No evidence of muscular or osseous involvement. No drainable fluid collections are apparent. Prominent cellulitis/edema of the foot is also evident without internal gas. Right hip arthroplasty. Reactive appearing right inguinal lymph nodes. IMPRESSION: Cellulitis BLE (bilateral lower extremity). Prominent cellulitis/edema of the foot is also evident without internal gas. Right hip arthroplasty. Reactive appearing right inguinal lymph nodes. REVIEW OF SYSTEMS: General: negative for fever, chills, sweats, weakness. Neurological: negative for headache, dizziness, confusion. Psychological: negative for anxiety, depression, agitation. Interview on 01/06/2023 at 3:37 PM, Resident #1 and representative (RP) said Resident #1 did not receive wound treatment every day as ordered by the physician and had not received wound care while on the COVID-19 unit. Resident #1's representative said that she believed the wounds were not treated every day as ordered and could have possibly caused infection. Resident #1's representative said the resident will not be returning to the facility and that Resident #1 did not report concerns to the facility. Resident #1's representative said the resident remained in the hospital and had not been diagnosed with gangrene, but that there were x-ray findings of gas under the tissue. Resident #1's representative said she had visited Resident #1 often at the nursing facility and had not noticed any change in her mood or behavior. Resident #1's representative said she did not realize that wound care was not being conducted on Resident #1 until Resident #1 told her after being sent to the hospital on 1/4/2023. Interview on 01/06/2023 at 2:04 PM, ADON A said Resident #1 had missed wound care over the weekend on Monday, 1/2/2023, when routine staff were off due to the holidays. ADON A said she was ultimately responsible for providing wound care along with ADON B, RN A, and RN B. ADON A said she had observed dates longer than two days on a dressing that should have been changed prior in accordance with physician orders. ADON A said nurses were aware that when wound care nurses are not available, treatment should be done in accordance with the orders. However, there were issues with agency nurses not doing treatments and that have been addressed numerous times. ADON A said she spoke with RN A and the DON spoke with agency staff about wounds being addressed and that it is serious to make sure they are getting done. ADON A said RN A explained that during wound treatments on 01/02/2023, one of the nurses tested positive for COVID-19 and RN A was pulled to the floor and did not complete remaining wound treatments. ADON A said RN A did not relay information on wound treatments not being completed on 01/02/2023 until after identifying that physician orders were not followed and talking with her. ADON A said she identified wound treatments were not completed as ordered by the physician upon treatment review on Tuesday, 01/03/2023. ADON A said on 01/03/2023, she reviewed treatment administration records and checked on residents when she noticed the date on the bandage for Resident #1 had not been changed. ADON A said the resident did not report any concerns. ADON A said she did not notify Resident #1's representatives that wound treatments not completed on 01/02/2023 and that the DON and wound care physician were notified and aware. Interview on 01/06/2023 at 11:55 AM, CNA A said she had to check resident wound dressings and get them up and ready. She said there were multiple times she noticed a resident's bandage was dated older than two days. CNA A said an unknown male spouse was upset a couple of weekends ago regarding his wife's wound care and believed she had the same dressing on from the hospital. CNA A said she did not remember the residents name, and that the spouse felt ADON A lied to him about the dressing being changed. Interview on 01/06/2023 at 3:33 PM, the Wound Care Physician said he had no concerns and was not aware of any residents not receiving wound care as ordered. The Wound Care Physician said he did not visit the COVID-19 unit to provide treatment and that nursing staff would be responsible for notifying him of any concerns. The Wound Care Physician said that ADON B conducted resident rounds with him once a week. Interview on 1/6/2023 at 3:43 PM, the DON said she was not aware of any wound care that was not provided and had no concerns with wound care provided by agency staff. She said RN A and RN B would be responsible for providing wound care on the weekends including Mondays. The DON said if wound care was not provided staff protocol was to notify her and the physician. She said if treatments and wound care was not provided it could affect all residents and the wound could get worse or progress. Interview on 1/06/2023 at 4:30 PM, ADON B said it was important for all residents to receive wound care treatment as ordered because the wounds can get worse, sepsis or infections may occur if the wound is bad enough, and if it is a physician's order, they must follow physician's orders. ADON B said wound care treatment was provided on the TAR. She said she never had a problem with someone not doing the treatments and has been employed since July 2022. ADON B said if a wound treatment was not done, she would first do the treatment, find out why the treatment was not completed, and work to find out what was going on with the nurse responsible for treatment and take action to see why the nurse was not completing her job. Interview on 1/10/2023 at 8:20 AM, RN A said she was new at the facility employed since December 2022. She said she was responsible for wound care along with RN B, ADON A, and ADON B. RN A said the last took care of Resident #1 on Monday, 1/2/2023, and did not conduct wound care on her. ADON A said she had talked to the agency nurse and a regularly employed nurse about how to provide wound care on the resident since she was pulled to the floor. ADON A said she did not remember the agency or facility employed nursing staff assigned to that unit she reviewed wound care information with. ADON A said the nurses assigned to that unit were responsible for conducting wound care for her that day, 1/2/2023, and did not know if wound care was completed on Resident #1. RN A said it was important for wound care to be provided per physician orders. It could lead to infection and lead to different things if it is not performed according to physician orders. Review of Employee Personnel Record for RN A revealed no disciplinary action letters or concerns. Record review of facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised April 2018, revealed that: 1. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.) and application of topical agents. 2. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to wound or to wound treatment, etc. Record review of facility's policy titled, Progressive Discipline, no date, revealed the following: The Company's philosophy is to hold each employee to a high standard of professional conduct. Employees must follow departmental procedures. Employees must perform responsibilities in an appropriate manner and at assigned times. Your supervisor will determine the appropriate level of discipline in each case.

Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents reviewed for pressure ulcers. (Resident #1, Resident #2, and Resident #3) 1. The facility failed to assess Resident #1's skin weekly which led to the resident being diagnosed with a stage 4 pressure wound (a very deep wound involving skin, muscle, and bone) to her sacrum (the bone between the spine and tailbone). The resident required hospitalization due to [CONDITION(S)] (the body's extreme reaction to an infection), and [CONDITION(S)] (an infection of the bone) of the sacrum due to the wound. 2. The facility failed to assess Resident #3's skin weekly and failed to provide Resident #2 and Resident #3 with consistent wound care to prevent further wound deterioration. These failures placed residents with skin breakdown at risk of pain, worsening of wounds, infection, emotional distress, harm, or death. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 4:50 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at the severity of actual harm that is not immediate jeopardy with a scope identified as a pattern due to the facility's need to evaluate the effectiveness of the corrective systems. Findings included: 1. Record review of Resident #1's face sheet, with a print date of [DATE], indicated she was [AGE] years old, admitted on [DATE], discharged on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's orders, with a print date of [DATE], indicated an order with a start date of [DATE] for cleansing the resident's buttocks with wound cleanser, pat dry, apply Dakin's solution, and gauze daily. Also noted was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's care plan, indicated a focus area, with an initiation date of [DATE] , of alteration to her skin integrity due to her history of pressure wounds. Interventions included a pressure relief cushion in her wheelchair, weekly skin assessments, monitoring for skin breakdown, performing treatments as ordered, conducting Braden scales, and keeping skin clean and dry. A focus area, with an initiation date of [DATE], indicated she was considered at risk for UTIs and skin breakdown due to her incontinence with interventions including weekly skin assessments, pressure relieving devices, monitor every 2 hours for incontinent episodes and appropriate care after each incontinent episode. Record review of Resident #1's MDS assessment, dated [DATE], indicated she had minimal hearing difficulty, unclear speech, usually understood and was understood by others, and had mild cognitive impairment. She was totally dependent on one staff member for bed mobility and toilet use. She was totally dependent on two staff members for transfers and required the extensive assistance of two staff members with personal hygiene. She used a wheelchair for ambulation. The MDS indicated she was at risk for developing pressure ulcers but had no pressure wounds present. Record review of Resident #1's most recent Braden scale, dated [DATE], indicated a score of 13, meaning the resident was at moderate risk of developing pressure wounds. Record review of Resident #1's most recent skin assessment, dated [DATE], indicated she had no skin issues. Record review of Resident #1's July MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's August MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's skin assessments through July and August revealed no documented skin assessments for dates [DATE], [DATE], [DATE], [DATE], or [DATE]. Record review of a nurse's note, completed by LVN A, dated [DATE] at 3 p.m., indicated LVN A was notified by CNA B about Resident #1 needing wound care to her buttocks. LVN A assessed the resident's wound and described it as being foul smelling with drainage, slough, and eschar (dry, dead tissue). LVN A notified the resident's family member, the wound care physician and the medical director and received treatment orders for the wound. Record review of a nurse's note, completed by LVN C, dated [DATE] at 5:29 p.m. indicated Resident #1 had an open area to her bottom with a treatment in place. She was to follow up with the wound care physician on [DATE]. LVN C said the resident refused to lay back down after her 10:00 a.m. smoke break. She said she attempted to educate the resident on the importance of laying back down so her wound would not worsen. The resident refused, saying she did not like to lay down and liked to roll around in her chair. Record review of a nurse's note, completed by an agency nurse , dated [DATE] at 1:37 p.m. indicated Resident #1 had an ulcer to her coccyx with treatments tolerated well. Resident #1 was non-compliant with relieving pressure off her wound and demanded to stay up in her chair all day. The agency nurse indicated the resident was given encouragement to lie down, but she would not. Record review of the wound care physician's note dated [DATE] indicated Resident #1 had an unstageable pressure wound to her sacrum measuring 8cm x 12cm x 4cm with 80% slough (dead bacteria, skin cells, and white blood cells) and 20% granulation tissue (new tissue and blood vessels). The wound was present for greater than 5 days and had light drainage. Record review of a nurse's note, completed by LVN C, dated [DATE] at 4:10 p.m., indicated Resident #1 was up in her wheelchair in her room, watching tv. The resident tolerated her wound treatment well but was still refusing to lay down. Record review of a nurse's note, completed by an agency nurse, dated [DATE] at 5:37 p.m., indicated Resident #1 was seen by the medical director and found to have altered mental status. The medical director ordered the resident be sent out for further evaluation and treatment on [DATE]. Record review of Resident #1's hospital records indicated she admitted on [DATE] with [CONDITION(S)] and a large wound. She was not a candidate for surgical intervention and hospice was suggested as the best option for her. Wound examination described the sacral bone as crumbling and necrotic (dead). Imaging conducted concluded the resident had air in her lower chest that had possibly entered through the wound. The infectious disease physician indicated the resident would not survive her wound with or without surgery and palliative care should be discussed. She discharged from the hospital to a different facility on [DATE]. During an observation on [DATE] at 11:10 a.m. of Resident #1's room contained a low air loss mattress and a pressure relieving cushion in her wheelchair. During an observation on [DATE] at 4:50 p.m. Resident #1 was seen in the ICU. She had been intubated (tube inserted through the mouth to keep the airway open so oxygen can be delivered to the lungs via a machine) earlier in the day and was on a ventilator (life support machine). The resident's wound was dressed and packed. After removal of the dressing and packing, the wound was noted to have a strong odor. The wound bed had white slough, dark colored eschar , and drainage. The resident's sacrum bone was visible. The wound was very large and very deep, larger than a softball, and displayed some granulation tissue. During a phone interview on [DATE] at 10:31 a.m., Resident #1's family member said she was at the hospital when the resident was turned over and she saw the resident's bottom for herself. She said it was a very large wound and was a stage 4. She said one of the physicians at the hospital said the wound to the resident's bottom was very bad and would need surgery, but he did not believe it was fixable. She said the hospital staff were trying to determine if the wound went down to the bone. She said she did not know if the facility had a wound care nurse on staff and did not know if the staff were showering the resident regularly. She said the resident had a [CONDITION(S)] bag (a piece of the colon is surgically placed externally to allow for waste collection in a bag) and she believed staff were not cleaning the resident's bottom since she doesn't poop. She said she had a care plan meeting with the activity director, and she was not sure who else, but she said they never mentioned anything about a wound to the resident's bottom. She said she was called by the facility and notified the medical director had ordered the resident be sent to the hospital. She said she went to the hospital and the medical director arrived as well. He told her the resident had been very lethargic at the facility, did not look like herself and was not behaving like herself. During attempted interviews calls were placed to CNA B on [DATE] at 10:38 a.m. and [DATE] at 2:48 p.m. Voice messages were left both times asking for a return call, but no return call was received. During an interview on [DATE] at 12:00 p.m. the administrator said she had implemented an immediate plan of correction, dated [DATE], regarding skin assessments and wound care. She said they identified there were issues with both. She said the plan addressed nurses completing skin assessments as indicated or at least weekly and CNAs to complete skin assessments per CNA protocol and upon showers. The DON, ADON, and administrator were to monitor this weekly and review shower sheets and skin assessment sheets. Wound treatments were also to be addressed by the nurses per orders from the wound care physician and medical director until the wound care nurse started on [DATE]. The DON, ADON, and administrator were to monitor weekly for treatment orders. During a phone interview on [DATE] at 1:39 p.m. hospital RN D said she was the nurse taking care of Resident #1 during her stay in the hospital. She said the resident's wound was a stage 4 and measured 10cm length x 14cm width x 5cm depth. She said there was no way the wound appeared on [DATE] and was as bad as it was by [DATE] when the resident admitted to the hospital. She said once the resident's wound was cleaned out, her sacrum was visible in the wound. She said the resident had [CONDITION(S)] in her pelvis and was on [MEDICATION(S)] (an antibiotic use to treat complicated infections). She said the resident was admitted due to altered mental status, fast heart rate, and a worsening of her wound. She said to her knowledge, the medical director of the facility was the person who sent the resident out and he was concerned about [CONDITION(S)]. She said the resident had 2 units of blood transfused after admission as well. She said they were hoping the resident could have surgery on her wound, but they were not sure if she would be a candidate for that. During a phone interview on [DATE] at 2:49 p.m. LVN A said she worked in the facility for a short amount of time, but Resident #1 was her resident. She said she was asked on [DATE] by CNA B if she was going to do the treatment to Resident #1's bottom before the aide got her up. She said she had no orders to do the treatment to the resident's bottom and was not told about a wound in shift change report. She said at that point she looked at the resident's bottom and noted slough, necrotic (dead) tissue, and a foul odor but she could not give the stage of the wound. She said she notified the administrator, who did not know the resident had the wound. She said she notified the doctor so she could get treatment orders and asked him what to do. She said she asked the other nurse working with her, LVN C, if she knew about the resident's bottom wound, and she said she did not. She said LVN C looked through the resident's chart and said RN E should have done the resident's skin assessment the night before, [DATE]. She said she showed RN E a picture of the wound and when RN E saw it, she said, I don't know what that is. She told RN E that was Resident #1's wound, and she should have seen it on her skin assessment the night before . She said RN E said, I've never seen that. She said the aides she worked with over the weekend, [DATE]-[DATE] were turning their residents every 2 hours like they should, but she could not say if other aides were turning the residents timely. She said she looked in the resident's nurse's notes for at least the previous month of care and saw nothing about the resident's wound. She said one of the aides tried to say they had bathed her the night before, but she was not sure how they could have not noticed the wound, or even the smell of it. During a phone interview on [DATE] at 4:10 p.m., the medical director said he did not realize Resident #1's wound was as big as it was until he saw it on [DATE]. He said when he saw the wound, he was shocked at the size of it. He said he had known the resident for many years, and he knew from looking at her that day that she was not her usual self. He said the resident had a previous stroke and had issues with communication, but she always knew who he was and was always happy to see him. He said when he saw her the morning of [DATE], she appeared very confused and did not know who he was. He knew then that she needed to be sent out. He said she had some [CONDITION(S)] (high heart rate) as well and he was unsure if the resident may have had another stroke, was septic, or some other condition. He said he went to the hospital to see the resident that day and had been following her since. He said she was septic, and they were treating her with [MEDICATION(S)]. She also had [CONDITION(S)] to her sacrum and her sacrum was visible once the wound had been cleaned out. He said he could not say definitively if the wound could have occurred and progressed to the point it was at on [DATE] with no one noticing it. He said he did see Resident #2 and Resident #3 as well. They both had wounds that he was aware of. He did not realize the residents were not having regular skin assessments and said that it was problematic they were not receiving them. During an interview on [DATE] at 10:20 a.m. the corporate RN said she saw Resident #1's wound for herself through pictures taken of it, and it looked as if the wound had not healed properly. She said the wound appeared to have healed over the top instead of the wound healing from the inside out. She said she believed there had been a wound in that area prior to this happening and it may have been old. During a phone interview on [DATE] at 10:39 a.m. LVN F said she was the treatment nurse for the facility until [DATE] but left. She was now a PRN employee and had not worked in a month. She said when she left, Resident #1 only had a small abrasion to her left glute (the large muscle of the buttock) from the brief. She said she did the weekly skin assessments for the residents when she was the treatment nurse. She said she went from wound care to the floor as a regular nurse. She said when she went back to the floor, the resident's skin assessments were to be passed off to the nurses caring for the residents. She said she worked in the facility for about a year and had not ever seen a wound to Resident #1's coccyx or sacrum. She said she made a conscious effort to turn the residents if the aides did not. She said she could not speak for everyone on if the residents were being turned and repositioned. She said Resident #1 was very adamant about going to all smoke breaks and not laying back down between the breaks. She said she asked for policies and procedures regarding wound care and skin assessments, but she was never given them. During an interview on [DATE] at 10:52 a.m. CNA G said she had not taken care of Resident #1 in about 3 or 4 weeks. She said she was not aware the resident had a wound on her bottom until around the time it was seen by the wound care physician. She said they work so understaffed, but there was no reason her bottom should have looked like that and there was no excuse for it. She said LVN C reported to her that it was a bad wound. She said the resident required brief changes and she did not understand how anyone didn't see or identify it. She said it was impossible to turn the residents every 2 hours and it was not being done like it should be. She said they have shower sheets and they're supposed to report any wounds or skin alterations they identify. During an interview on [DATE] at 11:18 a.m. CNA H said she did not see Resident #1's wound to her bottom when she was getting her ready for a shower and did not see it during her shower on [DATE] as she was laying on the shower chair. She said the resident kept pushing back on her and swatting her hands away when she would try to wash the resident's bottom. She said she was not told the resident had a wound on her bottom by the off going shift. She said she did not smell anything, and the resident had no complaints of pain. She said she tried her best to reposition the resident and turn her when she could. She said she was to notify the nurse when she identified a resident skin issue or alteration. During an interview on [DATE] at 12:48 p.m. LVN J said she had worked in the facility since [DATE]. She said resident skin assessments used to pop up in the EMAR, but it had not been doing that lately and she wasn't sure why. She said 100 hall had a skin assessment book that told the nurses what room to do, but they still had to do it in PCC (Point Click Care, an electronic charting system) She said no other hall had a skin assessment book. She said they used to have a treatment nurse that handled the skin assessments and wound care. She said when she was told by an aide there was a skin issue with a resident, she would go see the resident and assess. She said she was told a wound was found on Resident #1's bottom, but she did not know how anyone could have missed it. She said she had to tell agency staff that they were expected to do their own wound care and skin assessments because they did not know or were not told. She said she did not believe her residents were being turned every 2 hours as they were supposed to be. She said they seemed to have several high acuity and totally dependent residents clustered together, and she did not believe it would be possible for all residents to be turned every 2 hours. During an interview on [DATE] at 1:25 p.m. CNA K said she had not taken care of Resident #1 in a long while. She said she was in the facility the day the wound was identified though. She said she did not understand why anyone did not see the wound before then because from what she was told, it was very big and had tunneled. She said the resident was very adamant about going to smoke and refused to lay back down. She said the resident would say she was not wet, and a lot of the aides would take her word for it. She said she personally would not take the resident's word for it and would check the resident regardless. She said sometimes the resident would be dry as she said and other times she would be soaking wet. She said she did not understand how the resident's wound was so bad off and yet no one saw it. She said she did not think the aides were cleaning the resident's bottom as they were supposed to. She said she was supposed to report to the nurse whenever she saw a skin issue with the residents. She said she had seen agency aides not turning their residents every 2 hours as they were supposed to. She said she reported this to her nurse every time she saw it. She said she told the agency nurses that they must dress the resident's wounds after she bathed them. She said the RN supervisor did not do treatments on Saturday [DATE] because the key was locked in the cart, and she was not able to get into it. During an interview on [DATE] at 5:27 p.m. the DON said she told nurses who had asked her about the outstanding skin assessments to complete the assessments. She said she had no other way of communicating these things since she was not at the facility at night. She said there was a book on the 100 hall that outlined which skin assessments to do on what day but that was the only book she knew of. She said the wound care nurse was to start on [DATE], but the other floor nurses would still be responsible for their own skin assessments on residents not being seen by the wound care nurse. She said her in-service book was at the nurse's station, but she could not guarantee an agency nurse would look at it or sign it. During a phone interview on [DATE] at 6:41 p.m. the medical director said the nurse he spoke with on [DATE] portrayed the wound to be smaller than it was when he saw it on [DATE] He said the staff told him the wound had worsened over the past 2 days. He said had he known the wound was in the condition it was, he would have had the staff call the wound care physician instead of him. During an interview on [DATE] at 2:01 p.m. LVN C said she was not aware of Resident #1's wound because the wound was in a place where the only way to see it would have been during incontinent care. She said the aides did not often tell the nurses about Resident #1 refusing to lay down or wanting to stay in her chair. She said CNA B saw the resident's bottom and assumed, with how bad it was, the resident's bottom needed treatment. When CNA B asked if the nurse needed to do the treatment, the nurse was not aware there was a wound. She said the skin assessment reminders appeared in PCC with the options of yes or no. If staff clicked yes, the reminder went away. Staff then had to go into the skin assessment tool themselves and do the skin assessment. If staff clicked no, the reminder would stay active. She said there were skin treatments missed many times due to agency not wanting to do their own wound care. She said her residents were probably not getting turned every two hours because the aides were bogged down with all the high acuity and totally dependent residents. She said RN E was asked why she had not done the skin assessment on Resident #1 on [DATE] and RN E said, I don't know. During a phone interview on [DATE] at 2:50 p.m. RN E said she did not remember if she worked the night before Resident #1's wound was found. She said she performed her skin assessments at night as she was supposed to, and she documented them in PCC. She later said she assessed her resident's skin but did not document it. She denied seeing the resident's wound to her sacrum. She said when they did not have a wound care nurse the nurses were supposed to do the skin assessments themselves. She said she may have been overlooking the PCC documentation part of the assessments, but she did them. She said they had been putting [MEDICATION(S)] on a wound on Resident #1's left buttock, but she did not see the wound to the sacrum, and she was very surprised to hear about it. She said she had not been educated on wound care or skin assessments. She said they just got the order for wound care and then did whatever the order said. She said they just assessed whoever PCC said to for skin assessments that night. During a phone interview on [DATE] at 4:44 p.m. LVN L said she did not always do skin assessments when she was supposed to because there was no list available to look at. She said when she saw the reminders pop up in PCC, she did the skin assessments. She said the reminders did not always pop up. She denied knowing about Resident #1's wound before it was identified. During an interview on [DATE] at 9:45 a.m. the administrator said she was notified by Resident #1's family on [DATE] at 9:00 p.m. that Resident #1 had expired at the hospital. During an interview on [DATE] at 10:50 a.m. the administrator said she had just been made aware Resident #1 had not expired and was living at a different facility. She said they received a call from the other facility's business office manager requesting payment information for the resident. She said she did not know why the resident's family members would have reported she expired when she had not. During an interview on [DATE] at 9 a.m . with the admitting facility's wound care nurse indicated Resident #1 was now residing there. She said the most recent wound measurements were recorded as 17cm x 15cm x 7cm during her admission on [DATE]. Facility staff said she transferred to them on [DATE] from the hospital and was sent back to the hospital on [DATE] due to her being a full code and her oxygen saturation falling to 77% on room air and only increasing to 88% with oxygen. 2. Record review of Resident #2's face sheet, with a print date of [DATE], indicated she was [AGE] years old, admitted on [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's orders, with a print date [DATE], indicated an order with a start date of [DATE] to cleanse the open area to her right calf with wound cleanser, pat dry, apply calcium alginate and cover with a dry dressing. Another order, with an initiation date of [DATE], indicated to cleanse the open area to her left calf with wound cleanser, pat dry, and apply calcium alginate, then cover with a dry dressing. She was to have a skin assessment every Thursday on day shift and a pressure relieving mattress. Record review of Resident #2's care plan, with a focus area of potential for impaired skin integrity, with an initiation date of [DATE], indicated she had a pressure injury related to decreased mobility. Interventions included keeping her clean and dry, positioning with pillows, a pressure relief mattress and pressure relief cushion in her wheelchair, skin assessments every week and turn and reposition her every two hours. Another focus area of current skin concerns and at risk for further breakdown, with an initiation date of [DATE], included interventions of administer wound care as ordered, keep skin clean and dry monitor for increase in breakdown, position with pillows, pressure relief mattress and cushion, and weekly skin assessments. Record review of Resident #2's most recent MDS assessment, dated [DATE] indicated she had clear speech, understood and was understood by others, and had mild cognitive impairment. She was totally dependent on one staff member for toileting and personal hygiene. She required the assistance of two staff members for transfers. She used an electric wheelchair for ambulation. She had documented wounds and was at risk of developing pressure ulcers. Record review of Resident #2's most recent Braden scale, dated [DATE] indicated a score of 9, meaning the resident was at very high risk of developing pressure wounds. Record review of Resident #2's skin assessment, dated [DATE], was incomplete and had no measurements for her right calf wound. Record review of a nurses note by LVN F, dated [DATE] at 7:56 p.m. indicated Resident #2 had an old wound to her calf reopen. The wound care physician was notified, and an order was put in place. Record review of the wound care physician's note dated [DATE] indicated an old ulcer reopened to Resident #2's right calf and measured 7cm x 3cm x .1cm with moderate drainage and 100% slough. Record review of the wound care physician's note dated [DATE] indicates Resident #2's right calf wound had deteriorated and measured 14cm x 3cm x.1cm with moderate drainage. The physician indicated the wound was 30% slough, 40% granulation, 10% muscle/fascia, 20% skin. During an observation and interview on [DATE] at 11:15 a.m. Resident #2 was laying in her bed, she was awake and alert, watching tv. She had a low air loss mattress and a pressure relieving cushion in her electric wheelchair. She said she had a wound to her bottom and a wound to her right leg. She said she did not know when the wound to her right leg occurred, and the facility had to find it. She did not know how long the wound was there before it was found as she cannot feel her legs. She said she was sometimes turned, and needed help with turning and repositioning herself, but she did not frequently get turned and repositioned. She said it was rarely every 2 hours. She was laying on her back with no noted support. She said the nurse's provided wound care daily, but it had not been completed yet that day. During an interview on [DATE] at 11:40 a.m. agency LVN M said she was told to do wound care on her residents for the day. She said she knew to do skin assessments on her residents for the day but was not told by anyone to do them. She said she had not done wound care yet, but she would. During an interview on [DATE] at 11:50 a.m. agency LVN N said he knew where to look in PCC for resident skin assessments and he was sure to do them whether he was told to or not. He said he had already done his wound care on his residents and was also made aware they had wounds and treatments in place in shift report. During an observation and interview on [DATE] at 12:30 p.m. Resident #2 said her dressings were not changed on Saturday [DATE]. She said the dressing were changed on Sunday [DATE]. She said they were still not turning her like they should. She was laying on her back with no positioning devices. Her wounds had dressings, but they were not dated or initialed. During an observation and interview on [DATE] at 2:33 p.m. Resident #2 said her dressings had still not been changed. She was still laying on her back with no positioning devices in place. 3. Record review of Resident #3's face sheet, with a print date of [DATE], indicated she was [AGE] years old, admitted on [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #3's orders, with a print date of [DATE], indicated she had a pressure reducing mattress with an order date of [DATE]. She had an order, with an initiation date of [DATE], to cleanse her left knee with normal saline, pat dry, apply collagen and place a dry dressing daily until resolved. Another order, with an initiation date of [DATE], indicated she had a wound to her left inner lower calf with a treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . No order was noted for weekly skin assessments. Record review of Resident #3's care plan, with a focus area of alteration in skin integrity, with an initiation date of [DATE], indicated she had pressure ulcers and was at risk for skin breakdown due to immobility. Interventions included turning her every two hours, weekly skin assessments, a pressure reducing mattress, positioning with pillows, and monitoring for breakdown. Record review of Resident #3's most recent MDS assessment, dated [DATE], indicated she had no speech, never understood others and was never understood. She had short and long-term memory problems, severely impaired decision-making skills, continuous inattention and was totally dependent on one staff member for bed mobility, dressing, and eating. She was totally dependent on two staff members for toilet use and personal hygiene. The MDS indicated she had pressure wounds and was at risk for pressure wounds. It also indicated she had a pressure device for bed, nutrition interventions and treatments for her wounds. Record review of a nurse's note, dated [DATE] at 4:06 p.m. and completed by an agency nurse, indicated Resident #3 had a treatment administered to her left inner calf. Her left knee was noted to have an open wound measuring 2.5cm x 5cm with drainage noted. The physician was notified, and orders were received to cleanse the wound with normal saline, pat dry, apply collagen, and apply a dry dressing. The wound care physi [TRUNCATED]

Based on interview and record review, the facility failed to ensure adequate supervision was provided to prevent elopement for 2 of 6 residents reviewed for elopement. (Resident #'s 1 and 2) The facility did not develop interventions to prevent Resident #1 from leaving the facility without staff knowledge. Resident #1 was assessed as an elopement risk. Resident #1 was last seen at the facility at approximately 11:30 a.m. The resident got a ride with a stranger and was found at approximately 12:30 p.m. sitting on the porch of her old apartment approximately 1.5 miles from the facility. The facility did not implement effective interventions for Resident #2 when she attempted to leave the facility on multiple occasions. An Immediate Jeopardy (IJ) was identified on 08/15/19. While the IJ was removed 08/15/19; the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm, due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could place residents at risk for severe injury or death. Findings included: 1. A face sheet dated (MONTH) 2019 indicated Resident #1 admitted [DATE] and was [AGE] years old with a [DIAGNOSES REDACTED]. An elopement risk assessment dated [DATE] indicted Resident #1 was actively exit seeking, stated she needed to go home, and would walk home if she needed to. The assessment did not include elopement interventions. A baseline care plan dated 05/23/19 indicated Resident #1 had a cognitive impairment and had a potential for psychological well-being problems with risk for fluctuations in her mood/behaviors. The summary indicated Resident #1 was admitted from home with [DIAGNOSES REDACTED]. The baseline care plan did not address Resident #1's wandering or risk for elopement. The MDS dated [DATE] indicated Resident #1 had severely impaired cognition and wandered which placed her at severe risk of injury. A nursing note dated 05/23/19 at 7:03 p.m., indicated Resident #1 followed people out the front door and insisted she needed to go home even if she had to walk home. A nursing note dated 05/24/19 at 6:50 a.m., indicated Resident #1 requested to leave. A nursing note dated 05/25/19 at 9:40 a.m., indicated Resident #1 attempted to go out the front door. A nursing note dated 05/26/19 at 11:52 a.m., indicated Resident #1 asked how to get out so she could go home. A nursing note dated 05/26/19 at 7:24 p.m., indicated Resident #1 offered staff $10 to take her home. A nursing note dated 05/28/19 at 4:33 p.m., indicated Resident #1 needed a locked unit because she was a flight risk. A nursing note dated 05/29/19 at 12:00 p.m., indicated Resident #1 was found to be missing. The note indicated the resident's daughter called the facility and notified them Resident #1 had been found sitting on the porch of her old apartment. During an interview on 08/15/19 at 12:13 p.m., Resident #1's daughter said she received a call from the facility that her mother was missing on 05/29/19 at 12:39 p.m. She said she was scared to death. She said staff told her Resident #1 was last seen around 11:30 a.m. She said she immediately called her husband and instructed him to go around the apartment complex to see if he could find Resident #1. She said her husband called her back and told her Resident #1 was sitting on the porch of her old apartment. She said she called the facility and notified them Resident #1 had been found. Resident #1's daughter said the facility told her the resident could not come back to the facility because she needed to go to a place with a locked unit, and they could not provide that for her. She said she put Resident #1 in the nursing home because caring for Resident #1 became too much for her. She said her mother wandered at home, but she did not think she would ever be able to get out of the nursing home without being noticed. She said the Monday after Resident #1 was admitted to the facility, the administrator told her Resident #1 had gotten outside several times over the weekend. She said the administrator told her if Resident #1 got out of the facility one more time, then she would have to move to a facility with a locked unit. Resident #1's daughter said an employee of the water department told her Resident #1 was found walking down a local major highway about half a mile from the facility by a lady driving by. She said the water department employee told her the driver stopped to check on Resident #1, and Resident #1 got into her car. She said the water department employee said Resident #1 told the driver what road she lived on, so the driver took her to the apartment complex. During an observation on 8/15/19 at 9:30 a.m., it was noted the local highway where Resident #1 was picked up was a 4 lane divided highway with heavy traffic. The speed limit was 45 to 50 miles per hour between the facility and the location the resident was picked up by the citizen passing by. The website https://www.accuweather.com/en/us/kilgore-tx/ /may-weather/ 7 accessed on 8/29/19 indicated the high temperature on 5/29/19 was 90 degrees. During an interview on 08/15/19 at 2:59 p.m., LVN B said Resident #1 was an elopement risk. She said Resident #1 walked around with her purse and sat on the couch in the lobby like she was a visitor. She said she thought there was a protocol to follow if a resident was found to be an elopement risk, but she did not know what it was. She said random checks should have been done to make sure the resident was in the facility. She said the facility used to have the wander guard system to help prevent elopements, but she did not think they had it when Resident #1 eloped. She said she worked the day Resident #1 eloped. She said she went into Resident #1's room at approximately 11:30 a.m. She said she told Resident #1 it was time for lunch and she needed to come to the dining room. She said Resident #1 said she was not hungry. LVN B told Resident #1 her meal had already been paid for, so she might as well eat. LVN B said she was always in the dining room for lunch. She said trays were being passed and Resident #1 could not be found. She said residents started eating in the dining room, so she stayed in the dining room while the other staff started looking for Resident #1. During an interview on 08/15/19 at 1:25 p.m., the ADON said she was unsure if there was a policy indicating what interventions needed to be put into place if a resident was assessed as an elopement risk. She said she was not aware of Resident #1 having exit seeking behaviors. She said Resident #1 carried her purse around and attempted to put it under the nursing desk because she thought she worked at the facility. She said if the staff knew someone was an elopement risk, the resident would be checked on every 15 minutes. She said she did not know if Resident #1 was checked on every 15 minutes. 2. Physician orders [REDACTED].#2, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An elopement risk assessment dated [DATE] indicated Resident #2 was not an elopement due to weakness. The MDS dated [DATE] indicated Resident #2 had severely impaired cognition, inattention, disorganized thoughts, and wandered. A care plan revised 08/01/19 indicated Resident #2 had cognitive impairment. A care plan dated 8/15/19 indicated Resident #2 had episodes of adverse behaviors. The care plan did not address Resident #2's wandering or exit seeking. During an observation on 08/15/19 at 7:00 p.m., Resident #2 was self-propelling in the hallway telling staff she was looking for her husband. She was observed doing this on 2 of the 4 hallways. A nursing note dated 08/04/19 indicated Resident #2 attempted to get out all of the exits and threatened to hit and kick staff if they tried to stop her from leaving. The note indicated Resident #2 calmed down but continued to go from exit door to exit door. She was placed on every 15-minute monitoring. A nursing note dated 08/10/19 at 8:02 p.m. indicated Resident #2 went to all the exit doors and attempted to get out. The note indicated she approached people and asked how to get out and opened the exit door on Hall 4 which set the alarm off. During an interview on 8/15/19 at 2:55 p.m., LVN A said Resident #2 was the only resident currently in the facility that was an elopement risk. During an interview on 08/15/19 at 12:58 p.m., the DON said she was at a conference the day she received a phone call that Resident #1 was missing. She said Resident #1 looked like a visitor. She said Resident #1 sat on the couch in the lobby with her purse and walked around the facility. The DON said Resident #2 was currently the only resident that would go to the doors and try to get out. She said she would go to the exit door, open the door, and move away from the door because the alarm sounded. She said Resident #2 had been on every 15-minute checks, but she was not sure if she was currently on them. A policy regarding wandering, and unsafe residents, last revised (MONTH) 2014 indicated: . The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement . staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) .staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering .resident's care plan will indicate the resident is at risk for elopement and other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included . The facility's Plan of Removal was accepted on 08/15/19 at 7:55 p.m. and included: All current residents will be reevaluated for elopement risk within 18 hours by 12:30 p.m. 08/16 by DON, ADON, MDS/ADON, and Treatment ADON. Those residents that are deemed to be elopement risks will be placed on q (every) 15 minute checks until they no longer trigger as elopement risks or they are transferred to secured unit at another facility. This will be added to care plan and decision will be made if resident needs to be placed in a secured unit at another facility or is safe to remain in facility due to alarms on doors. 15 minute checks will be done by nurse and documented on q 15 minute monitoring form, and q shift on the nurses MAR. 2-10 staff on 08/15 and 10-6 and 6-2 staff on 08/16 will be in-serviced on Elopement risk and proper handling of residents who are elopement risks by ADON. Other staff members will be in-serviced as they report to work for next shift scheduled by ADON. A sign will be placed on entrance door to families and visitors to not let residents out doors without staff permission by administrator on 08/15/2019. On 08/16/19, the surveyor confirmed the plan of removal had been implemented sufficiently to remove the Immediate Jeopardy by: *The updated elopement assessments for residents at risk of elopement were reviewed and Resident #2 was assessed to be an elopement risk. *Entrance/exit doors were observed, and it was noted that signage was placed that instructed visitors not to allow anyone out of the building unless the staff had given approval. *During interviews on 08/15/19 and 08/16/19, 5 nurses (2 from day shift, 2 from evening shift, and 1 from night shift), 1 MA (from day shift), and 5 CNAs (2 from day shift and 3 from night shift) were interviewed and said they had been in-serviced on what to do when a resident was assessed to be a risk of elopement. Staff knew to report the missing resident to the DON and administrator who would notify the police, notify the resident's responsible party, search every part of the building along with the property, and the area (streets, neighborhoods, highway) surrounding the facility. Licensed nursing staff said when a resident was assessed to be an elopement risk they were to notify the DON and put the resident on every 15-minute checks and fill out the form for every 15-minute checks. On 08/16/19 at 9:25 a.m., the administrator was informed the Immediate Jeopardy was removed; however, the facility remained out of compliance at a scope of isolated with a potential for more than minimal harm due the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident #1) The facility did not ensure the lift gate was raised while unloading Resident #1. Resident #1 fell off the back off the back of van onto the lowered lift gate while being unloaded by a staff member resulting in the resident having a C-3 vertebrae fracture. This failure contributed to Resident #1's fractured C-3 vertebrae. This failure could place 58 residents who required assistive devices when traveling in the facility van at risk for accidents. Findings included: A Face sheet dated 11/30/17 indicated Resident #1 was [AGE] years old and admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #1 did not walk in his room or walk in the corridor and used a wheelchair as a mobility device. A care plan dated 11/21/17 indicated Resident #1 is at risk for falls related to impaired mobility and understanding physical deficits and one staff member is to assist with all ambulation and resident uses wheelchair for long distance mobility. Resident #1 was at risk for potential complications related to [DIAGNOSES REDACTED]. During a phone interview on 11/30/17 at 12:42 p.m., CNA A said she was the transportation driver and on 11/17/17 and transported Resident #1 and another resident whose name she could not remember back to the facility on [DATE]. She said the other resident was sitting in the front seat of the van and their wheelchair was secured in the back of the van along with Resident #1. CNA A said when she arrived back to the facility she went to the back of the van, opened the back doors and lowered the lift gate. CNA A said she rode the lift gate up and took the empty wheelchair for the resident in the front seat. CNA A said she lowered the lift gate down to the ground with the empty wheelchair and herself on it. Resident #1 was sitting in the back of the van in his secured wheelchair. CNA A said the lift remained on the ground and she transported the resident sitting in the front seat into the facility first. CNA A said she entered the side of the transportation van to unload Resident #1 and take him into the facility. CNA A said she did not raise the van lift gate up before she entered the side of the van. CNA A said she unsecured Resident #1's wheelchair. CNA A said she was in front of Resident #1 and pushed him backwards toward the back of the van toward the lift gate and Resident #1 fell out the back of the van. CNA A said the van lift gate was on the ground but should have been in the up position before unloading Resident #1 to the back of the van. CNA A said she was suspended during the investigation and was terminated from the facility. During an interview on 11/30/17 at 8:39 a.m., the administrator said on 11/17/17, CNA A did not have the lift gate in the up position when she was unloading Resident #1 and the resident fell off the back of the van. Resident #1 was sent to the hospital for evaluation and was diagnosed with [REDACTED]. The administrator said the facility did not have a transportation policy involving the proper way to unload multiple residents, but they were working on it. The administrator said on 11/17/17 van drivers were trained on how to unload residents and ensure the lift gate was up before transferring a resident to the lift gate. The hospital records dated 11/17/17 indicated Resident #1 had a fall and a small c-spine hairline fracture. Cat Scan Imaging report dated 11/17/17 indicated Resident #1 had a new nondisplaced hairline fracture through the C-3 spinal laminar arch without displacement. During an observation and interview on 11/30/17 at 11:40 a.m., Resident #1 was lying in his bed. Resident #1 said he did not remember falling from the van. Resident #1 said he fell in the bathroom and was sent to the hospital. Resident #1 said he had a fractured vertebrae from the fall and was not in any pain or discomfort from the fall. During an observation and interview on 11/30/17 at 9:02 a.m., CNA B, van driver, lowered the lift to the ground. CNA B rode the lift up until it was level with the back of the van. CNA B then placed a resident in a wheelchair on the lift gate and locked the wheelchair wheels. CNA B stepped onto the lift gate and lowered the resident and herself down to the ground. CNA B said she always ensured the lift gate was up and in a safe position when unloading residents. CNA B said the facility did not have a transportation policy unloading multiple residents from the van. She said she had recieved additional training on loading residents onto the van since the incident with Resident #1. An undated policy and procedure for transportation indicated the following .13. Drivers must provide support and oral directions to passengers. Such assistance shall also apply to the movement of wheelchairs and mobility-limited persons as they enter or exit the vehicle using the wheelchair lift. Such assistance shall also include stowage by the driver of mobility aids and folding wheelchairs . This policy did not include the proper way to unload multiple residents when using the wheelchair lift. During an interview on 11/30/17 at 1:38 p.m., the DON said 58 residents who required assistive devices when traveling rode the facility van.

Based on observation, interview, and record review, the facility failed to provide necessary treatment and services, based on the comprehensive assessment, to promote healing and prevent new pressure injuries from developing for 1 of 2 residents reviewed for pressure injuries. (Resident # 7) The facility did not implement interventions to prevent Resident #7 from developing pressure injuries. Resident #7 entered the facility with one stage 2 pressure injury on his sacrum. He was not provided treatment for [REDACTED]. The resident did not receive dietary interventions as ordered with each meal and was not provided pressure relief for his sacral pressure injury. The sacral wound worsened in size and he developed 3 new stage 2 pressure injuries on his sacrum nine days after he was admitted . This failure could place 45 residents receiving preventative skin care at risk for the development for new or the worsening of existing pressure injuries. Findings included: Physician orders [REDACTED].#7, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. An initial admission skin assessment (admitted [DATE]) indicated Resident #7 had a stage 2 pressure injury on his sacrum measuring 0.8 cm x 0.2 cm x 0 cm. The characteristics of the wound were not documented. The initial care plan dated 3/27/17 indicated Resident #7 required peri-care every 2 hours and as needed. The resident had a stage 2 pressure injury on his sacral area and required a puree diet and health shakes. A progress note dated 3/27/17 at 5:59 p.m. indicated Resident #7 was admitted . The resident required complete assist with all activities of daily living and was incontinent of bowel and bladder. A physician order [REDACTED].#7 was to receive a health shake with his meals. A physician order [REDACTED].#7's pressure injury on his sacral area was to be cleaned and a protective sponge was to be applied daily and as needed. The most recent dietary note dated 3/29/17 indicated Resident #7 was on a therapeutic nutritional supplement and health shakes with meals three times per day. The dietary note indicated Resident #7 had a wound on his sacral area. The goal indicated the resident had a nutritional risk related to a wound. Nutritional interventions were a puree diet and health shakes with meals. A weekly ulcer assessment dated [DATE] indicated Resident #7 had a stage 2 pressure injury on the sacrum measuring 1 cm x 1 cm x 0.1 cm. The assessment indicated the wound bed was shiny and moist pink with granulation, pink or beefy red tissue. There was no drainage and no odor. A late entry progress note dated 4/3/17 indicated Resident #7's physician was notified the resident's wound was larger and the wound did not have an order to treat. The telephone orders and nursing notes from 3/27/17 through 4/4/17 indicated Resident #7 did not receive a treatment to the stage 2 pressure ulcer. During an observation on 4/4/17 at 11:50 a.m., Resident #7 was lying in bed on his back. The head of the bed was up approximately 30 degrees. His was not on a specialized mattress. During an observation on 4/4/17 at 12:28 p.m., Resident #7 received his lunch tray. The resident did not receive a health shake. During an observation on 4/4/17 at 1:37 p.m., Resident #7 was lying in bed on his back. The head of the bed was up approximately 30 degrees. During an interview on 4/4/17 at 4:02 p.m., the DON said they did not have a wound care nurse. She said residents with major wounds went to the wound care clinic. The DON said documented wound measurements were from the wound care consultant that came to the facility or from the nurse for that resident. During an observation on 4/5/17 at 7:49 a.m., Resident #7 was lying in bed on his back. The head of the bed was up approximately 30 degrees. Resident #7's breakfast food tray did not contain a health shake. CNA A said she fed Resident #7 his breakfast and the resident did not receive a health shake. During an observation and interview on 4/5/17 at 8:06 a.m., Resident #7 was lying in bed on his back. The head of the bed was up approximately 30 degrees. The resident was not offloaded off of his sacrum. CNA A said the resident was not offloaded off of his backside. She said she did not offload the resident. During an observation and interview on 4/5/17 at 8:45 a.m. Resident #7 was in bed on his back. The head of the bed was up approximately 30 degrees. Resident #7 did not have a bandage on the pressure injury on his sacrum. LVN B said Resident #7 had a bath earlier and he had not put the bandage back on his pressure injury. Blood tinged drainage was noted on the back of Resident #7's brief. The following pressure injuries were noted: *Sacral stage 2 pressure injury #1 (admitted with) was 3.5 cm x 2 cm x 0 cm. *New stage 2 pressure injury #2 (above pressure injury #1) was 1 cm x 0.5 cm x 0 cm. *New stage 2 pressure injury #3 (between #1 and #2) was 0.8 x 0.6 x 0 cm. *New stage 2 pressure injury #4 (to the right of #1) was 1 cm x 1 cm x 0 cm. The DON said pressure injuries #2, #3, and #4 were all stage 2 and were facility acquired. During an interview on 4/5/17 at 8:09 a.m., the DON said all mattresses in the facility were pressure relief mattresses. She said a resident would not get a specialized mattress unless the resident had a stage 3 or 4 pressure ulcer. The DON said since Resident #7's pressure injury was larger she would notify the physician to see if they could change the treatment. During an interview on 4/5/17 at 10:28 a.m., the DON said Resident #7 had not been evaluated by the wound consultant yet. During an observation and interview 4/5/17 at 12:22 a.m., CNA D was feeding Resident #7 his lunch in the assisted dining room. CNA D said there was no health shake for Resident #7 and asked Was he supposed to have a health shake? During an interview on 4/5/17 at 12:31 p.m., the DON said Resident #7 should receive a health shake with his meal. During an interview on 4/5/17 at 1:15 p.m., LVN C said the wound consultant had not been to the facility in 3-4 months. She said it was up to the nurses to assess the wounds. During an interview on 4/5/17 at 2:42 p.m. Resident #7's physician said the wounds were due in part to shearing. The physician said she was notified yesterday the resident's wounds were getting larger. She said she did not remember if she was notified on 4/2/17 the resident's wounds had gotten larger. The physician said ordered duoderm every 3 days and as needed for the pressure ulcer on his sacrum. According to the Clinical Nursing Skills and Techniques, 8th Edition Perry and Potter 2014 page 448 a stage 2 pressure ulcer should be treated with a composite film [MEDICATION NAME] or hydrogel. A comment listed was limits shearing. A pressure ulcer/skin breakdown protocol dated March 2014 indicated . 1. The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss, and a history of pressure ulcer(s). 2. In addition, the nurse shall describe and document/report the following: a. full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue; b. pain assessment; c. Resident's mobility status; d. current treatments, including support surfaces; and e. all active diagnoses. 3. The staff will examine the skin of a new admission for ulcerations or alterations in skin . Cause identification: 1. The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such As diabetes or [MEDICAL CONDITION], overall medical instability, cancer, [MEDICAL CONDITION] causing a catabolic state, and macerated or friable skin . Treatment/Management: 1. The physician will authorize pertinent orders related to wound treatments, including wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents if indicated for type of skin alteration. a. nutritional status is associated with increased risk of pressure ulcer development . The website http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ accessed 4/7/17 indicated Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue . Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). The CMS-672 dated 4/4/17 indicated 45 residents received preventative skin care.

Based on observation, interview, and record review the facility failed to ensure allegations of abuse, neglect, and mistreatment were thoroughly investigated and reported immediately to the state agency for 5 of 16 residents reviewed for abuse and neglect. (Resident #s 4, 5, 10, 11, and 13) Resident #11 received a second degree burn to her thigh from a coffee burn. The resident was not assessed for her ability to handle the coffee and the facility was not monitoring the temperature of the coffee prior to the incident. The facility did not report the incident to the state agency. Resident #4 was identified as having severe cognitive impairment. The facility did not keep Peri Care (a blue liquid cleansing agent) out of Resident #4's reach. Peri Care was left opened on the table by Resident #4's bed. The resident was found holding a cup containing a blue liquid. The resident was sent to the ER to be evaluated for ingesting Peri Care. The facility was unable to provide an investigative report and did not report to the state agency. Resident #10 reported CNA F yelled at her and threatened to hit her. The allegation was not thoroughly investigated and reported to the state agency. Resident #13 reported CNA F was rude, loud, and pulled her legs apart roughly when she assisted her to the bathroom and told her she needed a diaper. The allegation was not thoroughly investigated and reported to the state agency. Resident # 5 received a fracture of unknown origin. The facility did not investigate and report to the state agency. Resident #13 choked to death on peanut butter. The facility did not report the unusual incident to the state agency. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 49 residents at risk for abuse and neglect. Findings included: 1. A physician order [REDACTED].#11 was [AGE] years old, admitted [DATE] and included [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #11 had unclear speech, was usually understood and usually understood others. She required extensive assistance of two for bed mobility, transfer dressing, and toilet use and required limited assistance in locomotion on and off the unit of one person. She was incontinent of bowel and bladder. She had an additional active [DIAGNOSES REDACTED]. The MDS indicated she offered no complaint of pain and indicated she had a second or third degree burn. A care plan dated [DATE] indicated Resident #11 would be followed by the wound care physician until burn healed, the resident was provided an insulated coffee mug with removable lid, nurses were to treat wound as ordered, and dietary would monitor coffee temperatures by protocol. The resident ' s care plan prior to the incident on [DATE] did not address how the resident handled hot coffee. A nurse note dated [DATE] at 3:00 p.m., indicated LVN C was told by Resident #11 that she had slipped out of her wheelchair and could not tell her who put her back in the chair. LVN C documented observing a large 6 inch by 5 inch skin tear on Resident #11 ' s left hip area and triple antibiotic ointment was applied and a dressing. The note indicated she notified the physician and the family. A facsimile report dated [DATE] at 4:17 p.m., indicated LVN C notified the nurse practitioner at 3:39 p.m. Resident #11 slipped out of her wheel chair this morning and had a skin tear that measured 6 x 5 inches on the left hip area. The report indicated the nurse said she cleaned the skin tear and had applied triple antibiotic ointment and a dressing. A nurse note dated [DATE] at 7:44 a.m., indicated the previous DON spoke with Resident #11 and determined she had not slipped out of her chair but had spilled coffee on herself while wheeling her wheelchair. A weekly nurse skin assessment dated [DATE] indicated Resident #11 had a large blistered burn area to the left outer, upper, and mid-thigh area caused by spilling coffee on herself. There were no measurements provided. An incident report with a revision date of [DATE] at 4:30 p.m. completed by the previous DON indicated Resident #11 complained yesterday evening that she slid out of her chair and spilled her coffee. Staff was unable to identify who helped her back in the chair and blisters were not noted on Resident #11 leg until she reported yesterday. The DON indicated on the morning of [DATE] Resident #11 said she did not fall out of the chair but that her coffee mug slid spilling the coffee in the chair and burned her. The incident report indicated treatment with [MEDICATION NAME] cream had been initiated on [DATE] but would be getting new orders. The incident report documented a burn injury to the left thigh caused by spilling hot coffee while self-propelling wheelchair. The incident report indicated the physician was notified on [DATE] at 3:02 p.m. and the nurse purchased an enclosed coffee mug and oriented Resident #11 and staff on its use. A wound care specialist initial evaluation date [DATE], indicated Resident #11 had a burn wound of the left, lateral thigh of at least 1 day duration. The wound measurement (length x width x depth) was 22.5 cm x 9.5 cm x 0.1 cm, with a wound surface area of 213.75 cm² and a moderate amount serous exudate with 100% granulation tissue. The evaluation indicated treatment orders for silver [MEDICATION NAME] and calcium alginate one time daily with dry protective dressing. During an interview on [DATE] at 10:40 a.m. the MDS coordinator said the previous DON and administrator did not call the state for an incident of a burn injury to Resident #11 ' s left thigh and she questioned them as to why they would not report. During an observation and interview on [DATE] at 12:30 p.m., the DM indicated prior to the incident on [DATE] they did not monitor the temperature of coffee in the dining room. The DM said they were instructed after Resident #11 was burned to cool the coffee with ice after brewing until it was 135º, and then they could place it on the serving bar in the dining room. The coffee dispenser was sitting on the serving cabinet in the dining room and was accessible to the residents. The DM dispensed a cup of coffee and the temperature was 135.2º. During an interview on [DATE] at 2:35 p.m., the DON said she was not working in the facility when Resident #11 was burned and she had not seen anything in the building where residents were assessed for safe handling of hot liquids. She said she was unsure how the DM determined to cool the coffee to 135º for residents who drank coffee. She said the incident was not reported to the state agency. During an interview on [DATE] at 2:40 p.m. the MDS coordinator said Resident #11 did not have an assessment regarding handling hot beverages. The MDS coordinator said she was not aware of any assessments determining if residents required assistance or required supervision when handling of hot liquids such as coffee. The MDS coordinator said she did not know how the DM determined that the coffee served at or below 135º would be safe. During an observation and interview on [DATE] at 2:45 p.m., Resident #11 said she was dispensing coffee from the coffee pot in the dining room and her coffee cup slipped and spilled on her and it really hurt. CNA M and CNA N transferred Resident #11 into her bed and exposed Resident #11 ' s left leg. The burn scar measured 11 inches from the scar margin beginning at the top of the left thigh approximate to the hip towards the knee and at its widest point 4 inches. During an interview on [DATE] at 3:14 p.m., LVN C said Resident # 11 told her she slipped out of her wheelchair on [DATE] and she noted she had a large skin tear on her left thigh. LVN C said Resident #11 had a 6 inch x 5 inch layer of skin peeled off of her thigh. LVN C said she reported Resident #11 had a skin tear to the physician on [DATE]. LVN C said on [DATE] she found Resident #11 sitting in her room in a gown and noted the area to her thigh. She said she was unable to identify who helped Resident #11 back into her wheelchair because she required assistance of 2 staff to transfer. LVN C said the area to the resident ' s thigh looked worse the next day and there were large blisters and at that time Resident #11 told her she spilled coffee on herself. LVN C said there were no witnesses to the incident. 2. Physician orders [REDACTED].#4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment, unclear speech, rarely understood others, and was rarely understood. The resident was dependent on staff for locomotion, required extensive assistance of 2 staff to dress and extensive assistance of 1 staff for feeding. A care plan with a review date of [DATE], indicated Resident #4 did not have an updated care plan that addressed the incident of [DATE] when he was sent for an emergency room evaluation due to incidental ingestion of Peri Care. The care plan did not address keeping the environment free of hazards due to Resident #4's cognitive deficit and risk identified when he was found to have a cup of blue liquid in his hand. The plan did not include interventions for Resident #4 regarding potential hazards of eating or drinking of non-food items after the incident on [DATE]. A physician progress notes [REDACTED].#4 had severe dementia, poor judgment and insight, was unable to offer complaints, and continued to have behavioral disturbances. A nurse progress note dated [DATE] at 12:00 a.m., completed by LVN A indicated Resident #4 was found in his room holding a cup containing a blue liquid and a bottle of Peri Care was open at the bedside. The physician was notified and Resident #4 was sent by ambulance to the ER for an evaluation. An emergency transport booking form dated [DATE] at 12:30 a.m., indicated Resident #4 was transported to a local hospital. An emergency transport booking form dated [DATE] at 3:00 a.m., indicated Resident #4 was returned to the facility. A hospital ER discharge instruction dated [DATE] indicated Resident #4 had been treated for [REDACTED]. During an observation on [DATE] at 2:55 p.m., Resident #4 was propped with his elbow on the bed and feet on the floor, he cried when spoken to and did not respond with understandable words. During an interview on [DATE] at 5:50 p.m., CNA H, said Resident #4 was found with an open bottle of Peri Care in his room on [DATE]. She said the DON in-serviced the staff after to the incident to remove all items from reach of residents that were designated keep out of the reach of children, and place them in a plastic bag. She was unable to identify who left the bottle of Peri Care within Resident #4 ' s reach. CNA H said CNA B worked the night of [DATE]. During an interview on [DATE] at 5:55 p.m., CNA B, said she worked the night of the incident on [DATE]. The CNA said when she made her first round around midnight she found Resident #4 sitting on the bedside with a cup in his hand and an open bottle of blue colored Peri Care at the bedside. She said she did not know who had left the Peri Care within Resident #4 ' s reach. She said she notified the charge nurse and the DON was called and Resident #4 was sent to the ER. CNA B said the DON provided an in-service after the incident on removing personal items from the bedside and put in a bag and place in a drawer. During an interview on [DATE] at 4:50 p.m., LVN A said around midnight on [DATE] Resident # 4 was sitting on the bedside with a cup containing a blue substance and noted an opened bottle of Peri Care at the bedside. She said the resident was sent to the ER. She said she did not document an incident report for Resident #4's possible ingestion of Peri Care. During an interview on [DATE] at 3:46 p.m. and 5:05 p.m., the DON said she could not remember what staff was on duty the night of [DATE] at midnight when Resident #4 was determined to have possibly ingested Peri Care. She said she believed the staff made an assumption Resident #4 drank the Peri Care because the bottle was open at the bedside. The DON said she did not have documentation of interviews or statements concerning Resident #4 ' s incident on [DATE]. The DON said she did not believe he drank the Peri Care because he was sent right back to the facility and the emergency room personnel said he had not ingested the Peri Care. The DON said she called corporate to discuss which incidents to report to the state agency and if it was an unknown injury to a resident with dementia they would have reported to the state agency. The DON said the previous administrator instructed her not to report this incident. The DON said the incident was not reported to the state agency. During an interview on [DATE] at 11:00 a.m., the administrator said he expected nursing staff to write an incident report if Resident #4 was suspected to have ingested Peri Care. He said the incident should have been fully investigated especially since the resident had dementia. He said, the investigation should have included staff interviews and all circumstances surrounding the incident. He said he would have notified the state agency, and would have in-serviced staff on accident prevention and hazards. The administrator said he did not find where the previous administrator had documentation of an investigation of the incident, or a report to the state agency. A Material Safety Data Sheet dated [DATE], indicated Peri-Care appeared light blue-green oleaginous semi-solid and was not considered a primary skin or eye irritant or toxic by oral ingestion. During an interview on [DATE] at 11:08 a.m., the administrator said he expected a full investigation of injuries to residents that were not witnessed and would provide staff training and follow up and report to the state agency. 3. Physician orders [REDACTED].#10 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. The latest MDS dated [DATE] indicated Resident #10 was understood, and usually understood others. She had verbal behavioral symptoms ,[DATE] days of 7 days. She required the assistance of 1 person to transfer. Resident #10's care plan dated [DATE] indicated she required the assistance of ,[DATE] staff to transfer. A grievance report form dated [DATE] indicated Resident #10 reported CNA F yelled at her and threatened to hit her. The grievance report indicated CNA F was suspended pending the investigation. The grievance report indicated the resolution for the grievance was Resident has a history of exhibiting manipulative behavior and she targets certain individuals . The report indicated the allegation was determined to be false. The report indicated the allegation was not called into the state agency. 4. The most recent MDS dated [DATE] indicated Resident #13 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. Resident #13 was usually understood and usually understood others. She had no behaviors. The MDS indicated Resident #13 required the assistance of 2 or more staff for bed mobility and transfers. A grievance report form dated [DATE] indicated Resident #13 had to wait over 1 hour for CNA assistance to be taken to the bathroom. The report documented Resident #13 indicated CNA F is rude and loud to her and pulled her legs apart roughly when she assisted her to the bathroom and told her she 'needed a diaper. ' The grievance report form indicated the administrator counseled the CNA regarding customer service. The grievance report indicated the resolution for the incident was the DON educated and counseled with the appropriate staff for resident's needs to be met to ensure quality of care, dignity, and resident's rights. The report indicated the incident was not called into the state agency. During an interview on [DATE] at 4:28 p.m., the administrator said Resident #13 had obviously received poor customer service. He said he would have investigated the incident first, then possibly would have called the state. The administrator said there is a big difference in poor customer service and abuse. The administrator said Resident #10 ' s allegation of the CNA yelling at her and threatening to hit her should have been called into the state agency. The administrator said the facility should call in any allegation even if it was unfounded. He said any allegation of abuse of any type should be called in to the state agency. During an interview on [DATE] at 3:30 p.m., the DON said the grievance dated [DATE] regarding Resident #10 should have been called into the state but the prior administrator would not let her call the grievance into the state. The DON said Resident #10 has a history of manipulative behavior. The DON said she did not work in the facility at the time of the grievance with Resident #13 and does not know why that was not called into the state agency. 5. Consolidated Physician orders [REDACTED].#5 was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], indicated Resident #5 required extensive 2 person assistance with ADL's, required extensive assistance with mobility, was always incontinent of bowel and bladder, and was severely cognitively impaired. Nursing notes [DATE] indicated Resident #5 was transferred to a local hospital due to altered mental status. A hospital progress note dated [DATE] indicated upon presentation to the emergency roiagnom on [DATE] Resident #5 had pain with range of motion. An x-ray was provided and Resident #5 was found to have a femoral neck fracture. The facility was notified of the fracture. The clinical record for Resident #5 from ,[DATE]-,[DATE] did not contain documentation regarding incidents or investigations regarding an injury of unknown origin. During an interview on [DATE] at 6:44 p.m., the administrator said he was not aware of the situation regarding Resident #5's [MEDICAL CONDITION]. The administrator indicated the previous administrator had not notified him of the incident or he would have had the facility call the incident in. The administrator said the incident had not been investigated or called in to the state agency. The DON said that incident occurred before her employment at the facility. During an interview on [DATE] at 11:10 a.m., Resident #5's family member said, Resident #5 was able to ambulate with poor balance prior to the [MEDICAL CONDITION]. The family member said since the resident fractured her hip she did not want to try to walk as much. She said in October of 2015 the facility notified her Resident #5 transferred to the emergency room due to her not acting right and her color not right. The family member said Resident #5 was found to have a [MEDICAL CONDITION] while at the hospital. The family member said when the resident returned to the facility the staff informed her Resident #5 fell about a day or 2 prior to her going to the ER. She indicated she could not remember with whom she spoke with from the facility at that time. The family member said she was told by the nurse she had not been notified of the fall because the fall had not seemed that bad. 6. The most recent MDS assessment dated [DATE] indicated Resident #13 required extensive assistance with two person assistance for transfers, and extensive assistance with one person assistance with hygiene and bathing. The resident had range of motion impairment on one side, was always continent of bowel, and was occasionally incontinent of bladder. A progress note dated [DATE] at 4:30 p.m. indicated LVN C found Resident # 13 at approximately 3:50 p.m. sitting in an electric scooter unresponsive. CPR initiated. A discharge summary dated [DATE] indicated Resident #13 discharged on [DATE] due to a choking episode. A progress note dated [DATE] at 5:00 p.m. indicated LVN C contacted local hospital and was informed that Resident #13 expired and the cause of death was choking on peanut butter. The note documented the resident's airway was blocked due to peanut butter. During an interview on [DATE] at 11:38 a.m., the administrator and the DON indicated the incident regarding Resident # 13's choking on peanut butter was not reported to the state agency. A nursing policy and procedure for reporting incidents to the state and home office with a revision date [DATE] [MEDICAL CONDITION] any hospitalization s resulting from an injury or unusual occurrence would be reported to the facility Risk Manager within 24 hours. An incident report would be written containing the resident injury and all facts and environmental factors surrounding the variance. Notify the physician and family member or legal guardian of all injury reports. Report Neglect Allegations: report serious accidental injury that results from a facility practice action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. Conduct or conditions that may be associated with neglect, abuse, or exploitation and result in serious injury must be reported to the state agency within 24 hours. An Abuse/Neglect policy and procedure dated [DATE] indicated the facility will provide and ensure the promotion and protection of resident rights. It is each individual ' s responsibility to recognize report and promptly follow up abuse or neglect allegations or suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Neglect defined as a failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Prevent, identify, investigate, and protect The administrator and DON were notified on [DATE] at 2:20 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:19 p.m. and included: Facility failed to properly assess, treat and notify physician of a burn injury. Facility failed to recognize that a fracture injury of unknown origin and a possible choking event should have been reported to DADS as possible neglect. Facility failed to investigate these events properly. Facility failed to recognize that the injury should have been reported as possible neglect to DADS. Abuse and Neglect in-service will be provided by (COO and Regional Compliance Nurse) to all staff available at this time within the facility and will continue until (DON and ADON) have all staff in-serviced by [DATE]. This will be an interactive face to face in-service. Examples of Abuse and neglect will be given along with role-playing. In-service to be given to (DON, ADON) by (the COO) on [DATE] to include: Reporting of incidents, what incidents are reportable, proper investigations, when to report and how to report. How to do a proper investigation: interviews of staff and residents, interview others who may be at risk, statement from perpetrator if identified, suspension pending investigation if an alleged perpetrator is identified. Any and all incidents that require treatment in-house or out need to be addressed immediately. Physician and Family must be notified. If available include your IDT and [MEDICATION NAME] MUST be reported within 24hours. On [DATE], the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During interviews 4 CNAs said they were in-serviced and informed staff was responsible with obtaining coffee from the kitchen staff, assisting residents with transporting of the hot liquids and they were to monitor the residents for safe handling of hot liquids. The CNAs indicated they were told a list of residents with cognitive impairment requiring supervision and assistance was located at the nursing station. The 4 CNAs said they were in-serviced to keep all personal care items out of reach of cognitively impaired residents and any items that indicated keep out of the reach of children should be removed and stored in cabinets. During interviews the DON and ADON said all staff present at the facility and prior to coming on duty was in-serviced regarding the new policy for providing hot liquids, safely transporting and monitoring residents for the ability to safely drink/handle. The DON and ADON said nursing staff were in-serviced regarding a hot liquid safety evaluation to be performed on admission, re-admission, and quarterly and with significant changes. They both indicated staff was also informed to keep all personal care items secured. The DON and ADON said they had received in-service on reporting allegations of abuse, neglect, and exploitation, performing a thorough investigation and how to report to the state agency. During interviews with the DM and 1 kitchen staff said they removed the coffee dispenser from the dining room and were instructed not to allow any resident to obtain their own coffee. They were to monitor the temperature of the coffee assure it was maintained between 130º-135º prior to serving. They had a list of residents who could not drink coffee unsupervised and were instructed that they could not provide the coffee unless the impaired resident was supervised. During interviews 3 nurses reported being in-serviced on completing hot liquid safety evaluations, staff should be monitoring all residents for safety of handling hot liquids, no personal care items should be available to residents and cognitively impaired residents monitored to ensure no personal care items are within reach. They were in-serviced on the policy and procedures for abuse and neglect and were able to identify the abuse coordinator, how, when and to whom to report allegations of and abuse/neglect. On [DATE] at 6:36 p.m., the administrator and DON were advised the Immediate Jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 49.

Based on observation, interview, and record review, the facility failed to develop and implement their written policies and procedures to prohibit mistreatment, neglect, or abuse for 5 of 16 residents reviewed for abuse and neglect. (Resident #s 4, 5, 10, 11, and 13) Resident #11 received a second degree burn to her thigh from a coffee burn. The resident was not assessed for her ability to handle the coffee and the facility was not monitoring the temperature of the coffee prior to the incident. The facility did not report the incident to the state agency. Resident #4 was identified as having severe cognitive impairment. The facility did not keep Peri Care (a blue liquid cleansing agent) out of Resident #4's reach. Peri Care was left opened on the table by Resident #4's bed. The resident was found holding a cup containing a blue liquid. The resident was sent to the ER to be evaluated for ingesting Peri Care. The facility was unable to provide an investigative report and did not report to the state agency. Resident #10 reported CNA F yelled at her and threatened to hit her. The allegation was not thoroughly investigated and reported to the state agency. Resident #13 reported CNA F was rude, loud, and pulled her legs apart roughly when she assisted her to the bathroom and told her she needed a diaper. The allegation was not thoroughly investigated and reported to the state agency. Resident # 5 received a fracture of unknown origin. The facility did not investigate and report to the state agency. Resident #13 choked to death on peanut butter. The facility did not report the unusual incident to the state agency. An Immediate Jeopardy situation was identified on [DATE]. The Immediate Jeopardy was removed on [DATE]. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the census of 49 residents at risk for abuse and neglect. Findings included: A nursing policy and procedure for reporting incidents to the state and home office with a revision date [DATE] [MEDICAL CONDITION] any hospitalization s resulting from an injury or unusual occurrence would be reported to the facility Risk Manager within 24 hours. An incident report would be written containing the resident injury and all facts and environmental factors surrounding the variance. Notify the physician and family member or legal guardian of all injury reports. Report Neglect Allegations: report serious accidental injury that results from a facility practice action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. Conduct or conditions that may be associated with neglect, abuse, or exploitation and result in serious injury must be reported to the state agency within 24 hours. An Abuse/Neglect policy and procedure dated [DATE] indicated the facility will provide and ensure the promotion and protection of resident rights. It is each individual ' s responsibility to recognize report and promptly follow up abuse or neglect allegations or suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Neglect defined as a failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Prevent, identify, investigate, and protect 1. A physician order [REDACTED].#11 was [AGE] years old, admitted [DATE] and included [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #11 had unclear speech, was usually understood and usually understood others. She required extensive assistance of two for bed mobility, transfer dressing, and toilet use and required limited assistance in locomotion on and off the unit of one person. She was incontinent of bowel and bladder. She had an additional active [DIAGNOSES REDACTED]. The MDS indicated she offered no complaint of pain and indicated she had a second or third degree burn. A care plan dated [DATE] indicated Resident #11 would be followed by the wound care physician until burn healed, the resident was provided an insulated coffee mug with removable lid, nurses were to treat wound as ordered, and dietary would monitor coffee temperatures by protocol. The resident ' s care plan prior to the incident on [DATE] did not address how the resident handled hot coffee. A nurse note dated [DATE] at 3:00 p.m., indicated LVN C was told by Resident #11 that she had slipped out of her wheelchair and could not tell her who put her back in the chair. LVN C documented observing a large 6 inch by 5 inch skin tear on Resident #11 ' s left hip area and triple antibiotic ointment was applied and a dressing. The note indicated she notified the physician and the family. A facsimile report dated [DATE] at 4:17 p.m., indicated LVN C notified the nurse practitioner at 3:39 p.m. Resident #11 slipped out of her wheel chair this morning and had a skin tear that measured 6 x 5 inches on the left hip area. The report indicated the nurse said she cleaned the skin tear and had applied triple antibiotic ointment and a dressing. A nurse note dated [DATE] at 7:44 a.m., indicated the previous DON spoke with Resident #11 and determined she had not slipped out of her chair but had spilled coffee on herself while wheeling her wheelchair. A weekly nurse skin assessment dated [DATE] indicated Resident #11 had a large blistered burn area to the left outer, upper, and mid-thigh area caused by spilling coffee on herself. There were no measurements provided. An incident report with a revision date of [DATE] at 4:30 p.m. completed by the previous DON indicated Resident #11 complained yesterday evening that she slid out of her chair and spilled her coffee. Staff was unable to identify who helped her back in the chair and blisters were not noted on Resident #11 leg until she reported yesterday. The DON indicated on the morning of [DATE] Resident #11 said she did not fall out of the chair but that her coffee mug slid spilling the coffee in the chair and burned her. The incident report indicated treatment with [MEDICATION NAME] cream had been initiated on [DATE] but would be getting new orders. The incident report documented a burn injury to the left thigh caused by spilling hot coffee while self-propelling wheelchair. The incident report indicated the physician was notified on [DATE] at 3:02 p.m. and the nurse purchased an enclosed coffee mug and oriented Resident #11 and staff on its use. A wound care specialist initial evaluation date [DATE], indicated Resident #11 had a burn wound of the left, lateral thigh of at least 1 day duration. The wound measurement (length x width x depth) was 22.5 cm x 9.5 cm x 0.1 cm, with a wound surface area of 213.75 cm² and a moderate amount serous exudate with 100% granulation tissue. The evaluation indicated treatment orders for silver [MEDICATION NAME] and calcium alginate one time daily with dry protective dressing. During an interview on [DATE] at 10:40 a.m. the MDS coordinator said the previous DON and administrator did not call the state for an incident of a burn injury to Resident #11 ' s left thigh and she questioned them as to why they would not report. During an observation and interview on [DATE] at 12:30 p.m., the DM indicated prior to the incident on [DATE] they did not monitor the temperature of coffee in the dining room. The DM said they were instructed after Resident #11 was burned to cool the coffee with ice after brewing until it was 135º, and then they could place it on the serving bar in the dining room. The coffee dispenser was sitting on the serving cabinet in the dining room and was accessible to the residents. The DM dispensed a cup of coffee and the temperature was 135.2º. During an interview on [DATE] at 2:35 p.m., the DON said she was not working in the facility when Resident #11 was burned and she had not seen anything in the building where residents were assessed for safe handling of hot liquids. She said she was unsure how the DM determined to cool the coffee to 135º for residents who drank coffee. She said the incident was not reported to the state agency. During an interview on [DATE] at 2:40 p.m. the MDS coordinator said Resident #11 did not have an assessment regarding handling hot beverages. The MDS coordinator said she was not aware of any assessments determining if residents required assistance or required supervision when handling of hot liquids such as coffee. The MDS coordinator said she did not know how the DM determined that the coffee served at or below 135º would be safe. During an observation and interview on [DATE] at 2:45 p.m., Resident #11 said she was dispensing coffee from the coffee pot in the dining room and her coffee cup slipped and spilled on her and it really hurt. CNA M and CNA N transferred Resident #11 into her bed and exposed Resident #11 ' s left leg. The burn scar measured 11 inches from the scar margin beginning at the top of the left thigh approximate to the hip towards the knee and at its widest point 4 inches. During an interview on [DATE] at 3:14 p.m., LVN C said Resident # 11 told her she slipped out of her wheelchair on [DATE] and she noted she had a large skin tear on her left thigh. LVN C said Resident #11 had a 6 inch x 5 inch layer of skin peeled off of her thigh. LVN C said she reported Resident #11 had a skin tear to the physician on [DATE]. LVN C said on [DATE] she found Resident #11 sitting in her room in a gown and noted the area to her thigh. She said she was unable to identify who helped Resident #11 back into her wheelchair because she required assistance of 2 staff to transfer. LVN C said the area to the resident ' s thigh looked worse the next day and there were large blisters and at that time Resident #11 told her she spilled coffee on herself. LVN C said there were no witnesses to the incident. 2. Physician orders [REDACTED].#4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment, unclear speech, rarely understood others, and was rarely understood. The resident was dependent on staff for locomotion, required extensive assistance of 2 staff to dress and extensive assistance of 1 staff for feeding. A care plan with a review date of [DATE], indicated Resident #4 did not have an updated care plan that addressed the incident of [DATE] when he was sent for an emergency room evaluation due to incidental ingestion of Peri Care. The care plan did not address keeping the environment free of hazards due to Resident #4's cognitive deficit and risk identified when he was found to have a cup of blue liquid in his hand. The plan did not include interventions for Resident #4 regarding potential hazards of eating or drinking of non-food items after the incident on [DATE]. A physician progress notes [REDACTED].#4 had severe dementia, poor judgment and insight, was unable to offer complaints, and continued to have behavioral disturbances. A nurse progress note dated [DATE] at 12:00 a.m., completed by LVN A indicated Resident #4 was found in his room holding a cup containing a blue liquid and a bottle of Peri Care was open at the bedside. The physician was notified and Resident #4 was sent by ambulance to the ER for an evaluation. An emergency transport booking form dated [DATE] at 12:30 a.m., indicated Resident #4 was transported to a local hospital. An emergency transport booking form dated [DATE] at 3:00 a.m., indicated Resident #4 was returned to the facility. A hospital ER discharge instruction dated [DATE] indicated Resident #4 had been treated for [REDACTED]. During an observation on [DATE] at 2:55 p.m., Resident #4 was propped with his elbow on the bed and feet on the floor, he cried when spoken to and did not respond with understandable words. During an interview on [DATE] at 5:50 p.m., CNA H, said Resident #4 was found with an open bottle of Peri Care in his room on [DATE]. She said the DON in-serviced the staff after to the incident to remove all items from reach of residents that were designated keep out of the reach of children, and place them in a plastic bag. She was unable to identify who left the bottle of Peri Care within Resident #4 ' s reach. CNA H said CNA B worked the night of [DATE]. During an interview on [DATE] at 5:55 p.m., CNA B, said she worked the night of the incident on [DATE]. The CNA said when she made her first round around midnight she found Resident #4 sitting on the bedside with a cup in his hand and an open bottle of blue colored Peri Care at the bedside. She said she did not know who had left the Peri Care within Resident #4 ' s reach. She said she notified the charge nurse and the DON was called and Resident #4 was sent to the ER. CNA B said the DON provided an in-service after the incident on removing personal items from the bedside and put in a bag and place in a drawer. During an interview on [DATE] at 4:50 p.m., LVN A said around midnight on [DATE] Resident # 4 was sitting on the bedside with a cup containing a blue substance and noted an opened bottle of Peri Care at the bedside. She said the resident was sent to the ER. She said she did not document an incident report for Resident #4's possible ingestion of Peri Care. During an interview on [DATE] at 3:46 p.m. and 5:05 p.m., the DON said she could not remember what staff was on duty the night of [DATE] at midnight when Resident #4 was determined to have possibly ingested Peri Care. She said she believed the staff made an assumption Resident #4 drank the Peri Care because the bottle was open at the bedside. The DON said she did not have documentation of interviews or statements concerning Resident #4 ' s incident on [DATE]. The DON said she did not believe he drank the Peri Care because he was sent right back to the facility and the emergency room personnel said he had not ingested the Peri Care. The DON said she called corporate to discuss which incidents to report to the state agency and if it was an unknown injury to a resident with dementia they would have reported to the state agency. The DON said the previous administrator instructed her not to report this incident. The DON said the incident was not reported to the state agency. During an interview on [DATE] at 11:00 a.m., the administrator said he expected nursing staff to write an incident report if Resident #4 was suspected to have ingested Peri Care. He said the incident should have been fully investigated especially since the resident had dementia. He said, the investigation should have included staff interviews and all circumstances surrounding the incident. He said he would have notified the state agency, and would have in-serviced staff on accident prevention and hazards. The administrator said he did not find where the previous administrator had documentation of an investigation of the incident, or a report to the state agency. A Material Safety Data Sheet dated [DATE], indicated Peri-Care appeared light blue-green oleaginous semi-solid and was not considered a primary skin or eye irritant or toxic by oral ingestion. During an interview on [DATE] at 11:08 a.m., the administrator said he expected a full investigation of injuries to residents that were not witnessed and would provide staff training and follow up and report to the state agency. 3. Physician orders [REDACTED].#10 was [AGE] years old, admitted on [DATE], and had [DIAGNOSES REDACTED]. The latest MDS dated [DATE] indicated Resident #10 was understood, and usually understood others. She had verbal behavioral symptoms ,[DATE] days of 7 days. She required the assistance of 1 person to transfer. Resident #10's care plan dated [DATE] indicated she required the assistance of ,[DATE] staff to transfer. A grievance report form dated [DATE] indicated Resident #10 reported CNA F yelled at her and threatened to hit her. The grievance report indicated CNA F was suspended pending the investigation. The grievance report indicated the resolution for the grievance was Resident has a history of exhibiting manipulative behavior and she targets certain individuals . The report indicated the allegation was determined to be false. The report indicated the allegation was not called into the state agency. 4. The latest MDS dated [DATE] indicated Resident #13 was [AGE] years old, admitted [DATE] and had [DIAGNOSES REDACTED]. Resident #13 was usually understood and usually understood others. She had no behaviors. The MDS indicated Resident #13 required the assistance of 2 or more staff for bed mobility and transfers. A grievance report form dated [DATE] indicated Resident #13 had to wait over 1 hour for CNA assistance to be taken to the bathroom. The report documented Resident #13 indicated CNA F is rude and loud to her and pulled her legs apart roughly when she assisted her to the bathroom and told her she 'needed a diaper. ' The grievance report form indicated the administrator counseled the CNA regarding customer service. The grievance report indicated the resolution for the incident was the DON educated and counseled with the appropriate staff for resident's needs to be met to ensure quality of care, dignity, and resident's rights. The report indicated the incident was not called into the state agency. During an interview on [DATE] at 4:28 p.m., the administrator said Resident #13 had obviously received poor customer service. He said he would have investigated the incident first, then possibly would have called the state. The administrator said there is a big difference in poor customer service and abuse. The administrator said Resident #10 ' s allegation of the CNA yelling at her and threatening to hit her should have been called into the state agency. The administrator said the facility should call in any allegation even if it was unfounded. He said any allegation of abuse of any type should be called in to the state agency. During an interview on [DATE] at 3:30 p.m., the DON said the grievance dated [DATE] regarding Resident #10 should have been called into the state but the prior administrator would not let her call the grievance into the state. The DON said Resident #10 has a history of manipulative behavior. The DON said she did not work in the facility at the time of the grievance with Resident #13 and does not know why that was not called into the state agency. 5. Consolidated Physician orders [REDACTED].#5 was a [AGE] year old female, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS, dated [DATE], indicated Resident #5 required extensive 2 person assistance with ADL's, was always incontinent of bowel and bladder, and was severely cognitively impaired. Nursing notes [DATE] indicated Resident #5 was transferred to a local hospital due to altered mental status. A hospital progress note dated [DATE] indicated upon presentation to the emergency roiagnom on [DATE] Resident #5 had pain with range of motion. An x-ray was provided and Resident #5 was found to have a femoral neck fracture. The facility was notified of the fracture. The clinical record for Resident #5 from ,[DATE]-,[DATE] did not contain documentation regarding incidents or investigations regarding an injury of unknown origin. During an interview on [DATE] at 6:44 p.m., the administrator said he was not aware of the situation regarding Resident #5's [MEDICAL CONDITION]. The administrator indicated the previous administrator had not notified him of the incident or he would have had the facility call the incident in. The administrator said the incident had not been investigated or called in to the state agency. The DON said that incident occurred before her employment at the facility. During an interview on [DATE] at 11:10 a.m., Resident #5's family member said, Resident #5 was able to ambulate with poor balance prior to the [MEDICAL CONDITION]. The family member said since the resident fractured her hip she did not want to try to walk as much. She said in October of 2015 the facility notified her Resident #5 transferred to the emergency room due to her not acting right and her color not right. The family member said Resident #5 was found to have a [MEDICAL CONDITION] while at the hospital. The family member said when the resident returned to the facility the staff informed her Resident #5 fell about a day or 2 prior to her going to the ER. She indicated she could not remember with whom she spoke with from the facility at that time. The family member said she was told by the nurse she had not been notified of the fall because the fall had not seemed that bad. The most recent MDS assessment dated [DATE] indicated Resident #13 required extensive assistance with two person assistance for transfers, and extensive assistance with one person assistance with hygiene and bathing. The resident had range of motion impairment on one side, was always continent of bowel, and was occasionally incontinent of bladder. A progress note dated [DATE] at 4:30 p.m. indicated LVN C found Resident # 13 at approximately 3:50 p.m. sitting in an electric scooter unresponsive. CPR initiated. A discharge summary dated [DATE] indicated Resident #13 discharged on [DATE] due to a choking episode. A progress note dated [DATE] at 5:00 p.m. indicated LVN C contacted local hospital and was informed that Resident #13 expired and the cause of death was choking on peanut butter. The note documented the resident's airway was blocked due to peanut butter. During an interview on [DATE] at 11:38 a.m., the administrator and the DON indicated the incident regarding Resident # 13's choking on peanut butter was not reported to the state agency. A nursing policy and procedure for reporting incidents to the state and home office with a revision date [DATE] [MEDICAL CONDITION] any hospitalization s resulting from an injury or unusual occurrence would be reported to the facility Risk Manager within 24 hours. An incident report would be written containing the resident injury and all facts and environmental factors surrounding the variance. Notify the physician and family member or legal guardian of all injury reports. Report Neglect Allegations: report serious accidental injury that results from a facility practice action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. Conduct or conditions that may be associated with neglect, abuse, or exploitation and result in serious injury must be reported to the state agency within 24 hours. An Abuse/Neglect policy and procedure dated [DATE] indicated the facility will provide and ensure the promotion and protection of resident rights. It is each individual ' s responsibility to recognize report and promptly follow up abuse or neglect allegations or suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Neglect defined as a failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Prevent, identify, investigate, and protect The administrator and DON were notified on [DATE] at 2:20 p.m., that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on [DATE] at 4:19 p.m. and included: Facility failed to properly assess, treat and notify physician of a burn injury. Facility failed to recognize that a fracture injury of unknown origin and a possible choking event should have been reported to DADS as possible neglect. Facility failed to investigate these events properly. Facility failed to recognize that the injury should have been reported as possible neglect to DADS. Abuse and Neglect in-service will be provided by (COO and Regional Compliance Nurse) to all staff available at this time within the facility and will continue until (DON and ADON) have all staff in-serviced by [DATE]. This will be an interactive face to face in-service. Examples of Abuse and neglect will be given along with role-playing. In-service to be given to (DON, ADON) by (the COO) on [DATE] to include: Reporting of incidents, what incidents are reportable, proper investigations, when to report and how to report. How to do a proper investigation: interviews of staff and residents, interview others who may be at risk, statement from perpetrator if identified, suspension pending investigation if an alleged perpetrator is identified. Any and all incidents that require treatment in-house or out need to be addressed immediately. Physician and Family must be notified. If available include your IDT and [MEDICATION NAME] MUST be reported within 24hours. On [DATE], the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During interviews 4 CNAs said they were in-serviced and informed staff was responsible with obtaining coffee from the kitchen staff, assisting residents with transporting of the hot liquids and they were to monitor the residents for safe handling of hot liquids. The CNAs indicated they were told a list of residents with cognitive impairment requiring supervision and assistance was located at the nursing station. The 4 CNAs said they were in-serviced to keep all personal care items out of reach of cognitively impaired residents and any items that indicated keep out of the reach of children should be removed and stored in cabinets. During interviews the DON and ADON said all staff present at the facility and prior to coming on duty was in-serviced regarding the new policy for providing hot liquids, safely transporting and monitoring residents for the ability to safely drink/handle. The DON and ADON said nursing staff were in-serviced regarding a hot liquid safety evaluation to be performed on admission, re-admission, and quarterly and with significant changes. They both indicated staff was also informed to keep all personal care items secured. The DON and ADON said they had received in-service on reporting allegations of abuse, neglect, and exploitation, performing a thorough investigation and how to report to the state agency. During interviews with the DM and 1 kitchen staff said they removed the coffee dispenser from the dining room and were instructed not to allow any resident to obtain their own coffee. They were to monitor the temperature of the coffee assure it was maintained between 130º-135º prior to serving. They had a list of residents who could not drink coffee unsupervised and were instructed that they could not provide the coffee unless the impaired resident was supervised. During interviews 3 nurses reported being in-serviced on completing hot liquid safety evaluations, staff should be monitoring all residents for safety of handling hot liquids, no personal care items should be available to residents and cognitively impaired residents monitored to ensure no personal care items are within reach. They were in-serviced on the policy and procedures for abuse and neglect and were able to identify the abuse coordinator, how, when and to whom to report allegations of and abuse/neglect. On [DATE] at 6:36 p.m., the administrator and DON were advised the Immediate Jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated [DATE] indicated a census of 49.

Based on observation, interview, and record review, the facility failed to implement their policies and procedures to prohibit neglect for 2 of 16 residents reviewed for neglect. (Resident #s 4 and 11) Resident #11 received a second degree burn to her thigh from a coffee burn. The resident was not assessed for her ability to handle the coffee and the facility was not monitoring the temperature of the coffee prior to the incident. The hot coffee dispenser remained accessible to residents after the burn 11/16/15 through 3/3/16. The facility did not keep Peri Care (a blue liquid cleansing agent) out of Resident #4's reach. Peri Care was left opened on the table by Resident #4's bed. The resident was found holding a cup containing a blue liquid. The resident was sent to the ER to be evaluated for ingesting Peri Care. This failure may have contributed to Resident #11's sustaining a large second degree burn to her thigh. An Immediate Jeopardy situation was identified on 03/03/16. The Immediate Jeopardy was removed on 03/04/16. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 7 residents who frequently drank coffee and 28 residents with cognitive impairment at risk for injury. Findings included: 1. A physician order [REDACTED].#11 was [AGE] years old, admitted [DATE] and included [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #11 had unclear speech, was usually understood and usually understood others. She required extensive assistance of two for bed mobility, transfer dressing, and toilet use and required limited assistance in locomotion on and off the unit of one person. She was incontinent of bowel and bladder. She had an additional active [DIAGNOSES REDACTED]. The MDS indicated she offered no complaint of pain and indicated she had a second or third degree burn. A nurse note dated 11/16/15 at 3:00 p.m., indicated LVN C was told by Resident #11 that she had slipped out of her wheelchair and could not tell her who put her back in the chair. LVN C documented observing a large 6 inch by 5 inch skin tear on Resident #11 ' s left hip area and triple antibiotic ointment was applied and a dressing. The note indicated she notified the physician and the family. A care plan dated 11/17/15 indicated Resident #11 would be followed by the wound care physician until burn healed, the resident was provided an insulated coffee mug with removable lid, nurses were to treat wound as ordered, and dietary would monitor coffee temperatures by protocol. The resident's care plan prior to the incident on 11/17/15 did not address how the resident handled hot coffee. An incident report with a revision date of 11/17/15 at 4:30 p.m. completed by the previous DON indicated Resident #11 complained yesterday evening that she slid out of her chair and spilled her coffee. Staff was unable to identify who helped her back in the chair and blisters were not noted on Resident #11's leg until she reported the incident yesterday. The DON indicated on the morning of November 17, 2015 Resident #11 said she did not fall out of the chair, but that her coffee mug slid spilling the coffee in the chair and burned her. The incident report indicated treatment with [MEDICATION NAME] cream had been initiated on 11/16/15 and they would be getting new orders. The incident report documented a burn injury to the left thigh caused by spilling hot coffee while self-propelling her wheelchair. The incident report indicated the physician was notified on 11/16/15 at 3:02 p.m. and the nurse purchased an enclosed coffee mug and oriented Resident #11 and staff on its use. During an observation and interview on 3/3/16 at 2:45 p.m., Resident #11 said she was dispensing coffee from the coffee pot in the dining room and her coffee cup slipped and spilled on her and it really hurt. Resident #11 was noted to have a burn scar with measurements of 11 inches from the scar margin beginning at the top of the left thigh approximate to the hip towards the knee and at its widest point 4 inches. During an interview on 3/3/16 at 3:14 p.m., LVN C said Resident # 11 told her she slipped out of her wheelchair on 11/16/15 and she noted she had a large skin tear on her left thigh. LVN C said Resident #11 had a 6 inch x 5 inch layer of skin peeled off of her thigh. LVN C said she reported Resident #11 had a skin tear to the physician on 11/16/15. LVN C said on 11/16/15 she found Resident #11 sitting in her room in a gown and noted the area to her thigh. She said she was unable to identify who helped Resident #11 back into her wheelchair because she required assistance of 2 staff to transfer. LVN C said the area to the resident ' s thigh looked worse the next day and there were large blisters and at that time Resident #11 told her she spilled coffee on herself. LVN C said there were no witnesses to the incident. During an interview on 3/4/16 at 10:55 a.m., cook L said Resident #11 tried to get her own coffee from the dispenser in the past. A weekly nurse skin assessment dated [DATE] indicated Resident #11 had a large blistered burn area to the left outer, upper, and mid-thigh area caused by spilling coffee on herself. There were no measurements provided. A wound care specialist initial evaluation date 11/17/15, indicated Resident #11 had a burn wound of the left, lateral thigh of at least 1 day duration. The wound measurement (length x width x depth) was 22.5 cm x 9.5 cm x 0.1 cm and a moderate amount serous exudate (thin, clear and watery drainage) with 100% granulation tissue (healing). The evaluation indicated treatment orders for silver [MEDICATION NAME] and calcium alginate one time daily with dry protective dressing. A wound care specialist evaluation dated 12/28/15 indicated Resident #11's wound size was now decreased to 9.0 x 2.5 x 0.1 cm. An order to discontinue silver [MEDICATION NAME] and add silver absorbing agent and cover with dry protective dressing was noted. A wound care specialist evaluation dated 1/8/16 indicated Resident #11's wound size was now decreased to 6.0 x 1.0 x depth, not measurable in cm. Thick adherent dead tissue was debrided via surgical excision. Some subcutaneous tissue was removed along with devitalized tissue. Post debridement depth of 0.1 cm. A wound care specialist evaluation dated 1/22/16 indicated Resident #11's wound size was 1.2 x 0.6 x not measurable in cm. The wound bed was covered with 100% granulation tissue. Orders were to discontinue the dry protective dressing to Resident 11's left thigh. During an observation and interview on 3/3/16 at 8:25 a.m., Resident #11 wheeled her wheelchair with gloved hands. She had an insulated coffee mug positioned between her left outer thigh and the wheelchair arm. She wheeled herself into her room. During an observation and interview on 3/3/16 at 12:22 p.m., Resident #11 was in the dining room sitting at a table alone eating her lunch. She had an insulated cup with a handle and lid and said the cup contained coffee. During an observation and interview on 3/3/16 at 12:30 p.m., the DM indicated prior to the incident on 11/16/15 they did not monitor the temperature of coffee in the dining room. The DM said they were instructed after Resident #11 was burned to cool the coffee with ice after brewing until it was 135º, and then they could place it on the serving bar in the dining room. The coffee dispenser was sitting on the serving cabinet in the dining room and was accessible to the residents. The DM dispensed a cup of coffee and the temperature was135.2º. Coffee temperature logs from November 18, 2015 to March 3, 2015 indicated the temperature after the coffee was brewed and after it was cooled prior to serving to residents. The temperature logs indicated the coffee after brewing ranged from 140º-180º and after cooling ranged from 130º to 175º. American Burn Association. Scald Injury Prevention Educator's Guide http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf accessed 3/2/16 indicated: GENERAL BACKGROUND INFORMATION ON [MEDICAL CONDITION] Although [MEDICAL CONDITION] happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Both behavioral and environmental measures may be needed to protect those vulnerable to scalds because of age or disability, or because they do not have control of the hot water temperature in multi-unit residential buildings. The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit/48 degrees Celsius. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140o F/60o C it takes only five seconds or less for a serious burn to occur1. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F /71-82o C, resulting in almost [MEDICAL CONDITION] will require surgery. Since immediate removal of the hot liquid from the skin may lessen severity, splash and [MEDICAL CONDITION] not be as deep [MEDICAL CONDITION] in a bathtub. High risk groups ¿¿ Older Adults Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults.2 Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. ¿¿ People With Disabilities or Special Need Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids.[MEDICAL CONDITION] the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Moving hot liquids can be extremely difficult for someone who uses a cane or walker. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person ' s intellect, perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. While the basic principles of scald prevention apply to the general population the additional concerns affecting these high risk groups must be addressed. Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Prevention of scald injuries is always preferable to treatment and can be largely accomplished through simple changes in behavior and in the home environment. Time and Temperature Relationship to Severe Burns4 Water temperature Time for a third degree burn to occur 155 F68o C 1 second 148o F 64o C 2 seconds 140o F 6 0o C 5 seconds 133o F 56o C 15 seconds 127o F 52o C 1 minute 124o F 51o C 3 minutes 120o F 48oC 5 minutes 100o F 37o C safe temperature for bathing During an interview on 3/3/16 at 2:35 p.m., the DON said she was not working in the facility when Resident #11 was burned and she had not seen anything in the building where residents were assessed for safe handling of hot liquids. She said she was unsure how the DM determined to cool the coffee to 135º for residents who drank coffee. During an interview on 3/3/16 at 2:40 p.m. the MDS coordinator said Resident #11 did not have an assessment regarding handling hot beverages. The MDS coordinator said she was not aware of any assessments determining if residents required assistance or required supervision when handling of hot liquids such as coffee. The MDS coordinator said she did not know how the DM determined that the coffee served at or below 135º would be safe. 2. Physician orders [REDACTED].#4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment, unclear speech, rarely understood others, and was rarely understood. The resident was dependent on staff for locomotion, required extensive assistance of 2 staff to dress and extensive assistance of 1 staff for feeding. A physician progress notes [REDACTED].#4 had severe dementia, poor judgment and insight, was unable to offer complaints, and continued to have behavioral disturbances. Resident #4's care plan with the latest review date of 2/4/16, did not address his risk for ingestion of potentially toxic substances or the need to keep his environment free of those items he might ingest due to his cognitive impairment. Resident #4's care plan did not address the incidental ingestion of Peri Care that caused an emergency evaluation on 2/10/16. During an interview on 3/1/16 at 4:50 p.m., LVN A said she observed Resident # 4 around midnight on 2/10/16 to be sitting on the bedside with a cup containing a blue substance and noted an opened bottle of Peri Care at the bedside. She said the resident was sent to the ER. She said she did not document an incident report for Resident #4's possible ingestion of Peri Care and she could not remember if she notified the family concerning Resident #4 being sent to the ER. A nurse progress note dated 2/10/16 at 12:00 a.m., completed by LVN A indicated Resident #4 was found in his room holding a cup containing a blue liquid and a bottle of Peri Care was open at the bedside. The physician was notified and Resident #4 was sent by ambulance to the ER for an evaluation. An emergency transport booking form dated 2/10/16 at 12:30 a.m., indicated Resident #4 was transported to a local hospital. An emergency transport booking form dated 2/10/16 at 3:00 a.m., indicated Resident #4 was returned to the facility. A hospital ER discharge instruction dated 2/10/16 indicated Resident #4 had been treated for [REDACTED]. During an interview on 2/29/16 at 5:50 p.m., CNA H, said Resident #4 was found with an open bottle of Peri Care in his room on 2/10/16 on the bedside table within his reach. She said the DON in-serviced the staff to remove all items from reach of residents that were designated keep out of the reach of children, and place them in a plastic bag. She was unable to identify who left the bottle of Peri Care within Resident #4 ' s reach. CNA H said CNA B worked the night of 2/10/16. During an interview on 2/29/16 at 5:55 p.m., CNA B, said she worked the night of the incident on 2/10/16. The CNA said when she made her first round around midnight she found Resident #4 sitting on the bedside with a cup in his hand containing blue residue present in the bottom of the cup and an open bottle of blue colored Peri Care at the bedside. She said she did not know who had left the Peri Care within Resident #4's reach. She said she notified the charge nurse and the DON was called and Resident #4 was sent to the ER. CNA B said the DON provided an in-service after the incident on removing personal items from the bedside and put in a bag and place in a drawer. During an observation on 2/29/16 at 5:45 p.m., Resident #4 was sitting in the assisted dining room in a Geri-chair feeding himself and drinking from his cup. During an interview on 2/29/16 at 3:46 p.m. and 5:05 p.m., the DON said she could not remember which staff was on duty the night of 2/10/16 at midnight when Resident #4 was determined to have possibly ingested Peri Care. She said she believed the staff made an assumption Resident #4 drank the Peri Care because the bottle was open at the bedside. The DON said she did not have documentation of interviews or statements concerning Resident #4's incident on 2/10/16. The DON said she did not believe he drank the Peri Care because he was sent right back to the facility and the emergency room personnel said he had not ingested the Peri Care. During an observation on 3/1/16 at 9:50 a.m., Resident #4 was in the hall near the nursing station, attended by three staff members. The resident would rise from his Geri-chair and stand in a stooped position. During an interview on 3/1/16 at 2:06 p.m., Resident #4 ' s son said he was not notified of the incidental ingestion of Peri Care and did not know his dad was sent to the emergency department room on 2/10/16. During an interview on 3/2/16 at 11:00 a.m., the administrator said he expected nursing staff to write an incident report if Resident #4 was suspected to have ingested Peri Car. He said the incident should have been fully investigated especially since the resident had dementia. He said he would have notified the state agency, and would have in-serviced staff on accident prevention and hazards. A Material Safety Data Sheet dated January 30, 1991, indicated Peri-Care appeared light blue-green oleaginous semi-solid and was not considered a primary skin or eye irritant or toxic by oral ingestion. During an interview on 3/2/16 at 11:08 a.m., the administrator said he expected a full investigation of injuries to residents that were not witnessed and would provide staff training and follow up and report to the state agency. A nursing policy and procedure for reporting incidents to the state and home office with a revision date 1/8/07 [MEDICAL CONDITION] any hospitalization s resulting from an injury or unusual occurrence would be reported to the facility Risk Manager within 24 hours. An incident report would be written containing the resident injury and all facts and environmental factors surrounding the variance. Notify the physician and family member or legal guardian of all injury reports. Report Neglect Allegations: report serious accidental injury that results from a facility practice action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. Conduct or conditions that may be associated with neglect, abuse, or exploitation and result in serious injury must be reported to the state agency within 24 hours. An Abuse/Neglect policy and procedure dated 1/8/03 indicated the facility will provide and ensure the promotion and protection of resident rights. It is each individual ' s responsibility to recognize report and promptly follow up abuse or neglect allegations or suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Neglect defined as a failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Prevent, identify, investigate, and protect The administrator and DON were notified on 3/3/16 at 3:23 p.m, that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 3/3/16 at 8:15 p.m. and included: 1. Facility failed to monitor coffee temperature to [MEDICAL CONDITION] failed to supervise resident getting coffee. Facility failed to identify those Residents at risk for injury self- serving and drinking coffee. Coffee temps at the time of this incident were at temperatures that could cause burn injuries. (Registered Dieticians) recommends coffee to be served at 130-135 degrees to prevent burns. 2. We acknowledge that a resident was burned with coffee on 11/16/15. This Resident did not report burn until 11/17/15. An assessment, treatment, investigation and self-report to DADS should have been completed. The facility failed to assess and provide treatment in a timely manner. The facility failed to notify Physician. This is an unacceptable practice. An in-service was conducted on 03/02/16 on abuse, neglect, misappropriation and when, how and who to report to. Also the 03-02-16 in-service covered how to use the STOP and Watch tool to recognize changes of condition. All staff will be in-serviced on recognizing hazards and when to report incidents by DON on 3/4/16. (Administrator) will in-service (DON and ADON) on when and how to self-report incidents to DADS 3/4/16. Nursing staff will be in-serviced on assessment and notification of physician by DON on 3/4/16. 3. Coffee has been moved into the kitchen. Kitchen staff, specifically the dietary aide will ensure coffee is proper temperature prior to serving coffee. Clip board will be kept next to coffee pot and when temperature reaches 130 degrees, staff will initial, date and time it. They will check coffee every 10 minutes until appropriate temperature of 130-135 F degrees is reached. 4. Signs will be placed at both kitchen doors that state Please ask for coffee. 5. Resident counsel president and frequent coffee drinkers met with (administrator) to discuss plan to move coffee into kitchen for resident safety and have agreed with the plan. 6. Staff will be in-serviced by 3/4/16 that coffee has been moved into the kitchen and it must be asked for due to the hazards [MEDICAL CONDITION] hot liquids and the temperature of the coffee should not exceed 135. 7. Dietary staff have been in-serviced by (dietary manager) on the reason to move coffee into kitchen and that it must be available at all times while kitchen is open. Action plan that is currently in place has dietary staff cooling coffee to 130- 135 F degrees before serving. As of this time there have been no complaints about coffee temperature and no injuries since coffee has been being monitored and served at the new lower temp of 130-135F. 8. All residents that have the ability to drink coffee (take fluids/nutrition by mouth) will be assessed for safe handling of hot liquids by nursing and therapy staff by the completion of noon meal on 3/4/16. After completion of assessments, appropriate interventions will be put in place, eg; (cup with lid, drink beverage only at a table, staff to assist resident with hot beverages, wear splint if indicated, resident to wear clothing protector) On 03/04/16, the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During interviews 4 CNAs said they were in-serviced and informed staff was responsible with obtaining coffee from the kitchen staff, assisting residents with transporting of the hot liquids and they were to monitor the residents for safe handling of hot liquids. The CNAs indicated they were told a list of residents with cognitive impairment requiring supervision and assistance was located at the nursing station. The 4 CNAs said they were in-serviced to keep all personal care items out of reach of cognitively impaired residents and any items that indicated keep out of the reach of children should be removed and stored in cabinets. All were familiar with the facility abuse/neglect policies and procedures, and none were aware of any abuse/neglect in the facility. All knew what steps to take if they became aware of abuse issues, concerning protection, reporting, and prevention. During interviews the DON and ADON said all staff present at the facility and prior to coming on duty was in-serviced regarding the new policy for providing hot liquids, safely transporting and monitoring residents for the ability to safely drink/handle. The DON and ADON said nursing staff were in-serviced regarding a hot liquid safety evaluation to be performed on admission, re-admission, and quarterly and with significant changes. They both indicated staff was also informed to keep all personal care items secured. The DON and ADON said they had received in-service for investigating incidents and reporting to the state agency. During interviews with the DM and 1 kitchen staff said they removed the coffee dispenser from the dining room and were instructed not to allow any resident to obtain their own coffee. They were to monitor the temperature of the coffee assure it was maintained between 130º-135º prior to serving. They had a list of residents who could not drink coffee unsupervised and were instructed that they could not provide the coffee unless the impaired resident was supervised. During interviews 3 nurses reported being in-serviced on completing hot liquid safety evaluations, staff should be monitoring all residents for safety of handling hot liquids, no personal care items should be available to residents and cognitively impaired residents monitored to ensure no personal care items are within reach. During interviews with 3 frontline supervisors, all were familiar with the facility abuse/neglect policies and procedures, and none were aware of any abuse/neglect in the facility. All knew what steps to take if they became aware of abuse/neglect issues, concerning protection, reporting, and prevention. All were aware of their duty to monitor staff, and report and intervene as needed. On 3/4/16 at 6:36 p.m., the administrator and DON were advised the Immediate Jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 2/29/16 indicated 28 residents were identified with cognitive impairment and an undated list indicated 7 residents frequently drank coffee

Based on observation, interview, and record review the facility failed to ensure adequate supervision was provided to prevent accidents for 2 of 16 residents reviewed for accidents. (Resident #s 4 and 11) Resident #11 received a second degree burn to her thigh from a coffee burn. The resident was not assessed for her ability to handle the coffee and the facility was not monitoring the temperature of the coffee prior to the incident. The hot coffee dispenser remained accessible to residents after the burn 11/16/15 through 3/3/16. The facility did not keep Peri Care (a blue liquid cleansing agent) out of Resident #4's reach. Peri Care was left opened on the table by Resident #4's bed. The resident was found holding a cup containing a blue liquid. The resident was sent to the ER to be evaluated for ingesting Peri Care. This failure may have contributed to Resident #11's sustaining a large second degree burn to her thigh. An Immediate Jeopardy situation was identified on 03/03/16. The Immediate Jeopardy was removed on 03/04/16. The facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place 7 residents who frequently drank coffee and 28 residents with cognitive impairment at risk for injury. Findings included: 1. A physician order [REDACTED].#11 was [AGE] years old, admitted [DATE] and included [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #11 had unclear speech, was usually understood and usually understood others. She required extensive assistance of two for bed mobility, transfer dressing, and toilet use and required limited assistance in locomotion on and off the unit of one person. She was incontinent of bowel and bladder. She had an additional active [DIAGNOSES REDACTED]. The MDS indicated she offered no complaint of pain and indicated she had a second or third degree burn. A nurse note dated 11/16/15 at 3:00 p.m., indicated LVN C was told by Resident #11 that she had slipped out of her wheelchair and could not tell her who put her back in the chair. LVN C documented observing a large 6 inch by 5 inch skin tear on Resident #11 ' s left hip area and triple antibiotic ointment was applied and a dressing. The note indicated she notified the physician and the family. A care plan dated 11/17/15 indicated Resident #11 would be followed by the wound care physician until burn healed, the resident was provided an insulated coffee mug with removable lid, nurses were to treat wound as ordered, and dietary would monitor coffee temperatures by protocol. The resident ' s care plan prior to the incident on 11/17/15 did not address how the resident handled hot coffee. An incident report with a revision date of 11/17/15 at 4:30 p.m. completed by the previous DON indicated Resident #11 complained yesterday evening that she slid out of her chair and spilled her coffee. Staff was unable to identify who helped her back in the chair and blisters were not noted on Resident #11's leg until she reported the incident yesterday. The DON indicated on the morning of November 17, 2015 Resident #11 said she did not fall out of the chair, but that her coffee mug slid spilling the coffee in the chair and burned her. The incident report indicated treatment with silvadene cream had been initiated on 11/16/15 and they would be getting new orders. The incident report documented a burn injury to the left thigh caused by spilling hot coffee while self-propelling her wheelchair. The incident report indicated the physician was notified on 11/16/15 at 3:02 p.m. and the nurse purchased an enclosed coffee mug and oriented Resident #11 and staff on its use. During an observation and interview on 3/3/16 at 2:45 p.m., Resident #11 said she was dispensing coffee from the coffee pot in the dining room and her coffee cup slipped and spilled on her and it really hurt. Resident #11 was noted to have a burn scar with measurements of 11 inches from the scar margin beginning at the top of the left thigh approximate to the hip towards the knee and at its widest point 4 inches. During an interview on 3/3/16 at 3:14 p.m., LVN C said Resident # 11 told her she slipped out of her wheelchair on 11/16/15 and she noted she had a large skin tear on her left thigh. LVN C said Resident #11 had a 6 inch x 5 inch layer of skin peeled off of her thigh. LVN C said she reported Resident #11 had a skin tear to the physician on 11/16/15. LVN C said on 11/16/15 she found Resident #11 sitting in her room in a gown and noted the area to her thigh. She said she was unable to identify who helped Resident #11 back into her wheelchair because she required assistance of 2 staff to transfer. LVN C said the area to the resident ' s thigh looked worse the next day and there were large blisters and at that time Resident #11 told her she spilled coffee on herself. LVN C said there were no witnesses to the incident. During an interview on 3/4/16 at 10:55 a.m., cook L said Resident #11 tried to get her own coffee from the dispenser in the past. A weekly nurse skin assessment dated [DATE] indicated Resident #11 had a large blistered burn area to the left outer, upper, and mid-thigh area caused by spilling coffee on herself. There were no measurements provided. A wound care specialist initial evaluation date 11/17/15, indicated Resident #11 had a burn wound of the left, lateral thigh of at least 1 day duration. The wound measurement (length x width x depth) was 22.5 cm x 9.5 cm x 0.1 cm and a moderate amount serous exudate (thin, clear and watery drainage) with 100% granulation tissue (healing). The evaluation indicated treatment orders for silver sulfadiazine and calcium alginate one time daily with dry protective dressing. A wound care specialist evaluation dated 12/28/15 indicated Resident #11's wound size was now decreased to 9.0 x 2.5 x 0.1 cm. An order to discontinue silver sulfadiazine and add silver absorbing agent and cover with dry protective dressing was noted. A wound care specialist evaluation dated 1/8/16 indicated Resident #11's wound size was now decreased to 6.0 x 1.0 x depth, not measurable in cm. Thick adherent dead tissue was debrided via surgical excision. Some subcutaneous tissue was removed along with devitalized tissue. Post debridement depth of 0.1 cm. A wound care specialist evaluation dated 1/22/16 indicated Resident #11's wound size was 1.2 x 0.6 x not measurable in cm. The wound bed was covered with 100% granulation tissue. Orders were to discontinue the dry protective dressing to Resident 11's left thigh. During an observation and interview on 3/3/16 at 8:25 a.m., Resident #11 wheeled her wheelchair with gloved hands. She had an insulated coffee mug positioned between her left outer thigh and the wheelchair arm. She wheeled herself into her room. During an observation and interview on 3/3/16 at 12:22 p.m., Resident #11 was in the dining room sitting at a table alone eating her lunch. She had an insulated cup with a handle and lid and said the cup contained coffee. During an observation and interview on 3/3/16 at 12:30 p.m., the DM indicated prior to the incident on 11/16/15 they did not monitor the temperature of coffee in the dining room. The DM said they were instructed after Resident #11 was burned to cool the coffee with ice after brewing until it was 135º, and then they could place it on the serving bar in the dining room. The coffee dispenser was sitting on the serving cabinet in the dining room and was accessible to the residents. The DM dispensed a cup of coffee and the temperature was135.2º. Coffee temperature logs from November 18, 2015 to March 3, 2015 indicated the temperature after the coffee was brewed and after it was cooled prior to serving to residents. The temperature logs indicated the coffee after brewing ranged from 140º-180º and after cooling ranged from 130º to 175º. American Burn Association. Scald Injury Prevention Educator's Guide http://www.ameriburn.org/Preven/ScaldInjuryEducator'sGuide.pdf accessed 3/2/16 indicated: GENERAL BACKGROUND INFORMATION ON SCALD BURNS Although scald burns can happen to anyone, young children, older adults and people with disabilities are the most likely to incur such injuries. Both behavioral and environmental measures may be needed to protect those vulnerable to scalds because of age or disability, or because they do not have control of the hot water temperature in multi-unit residential buildings. The severity of a scald injury depends on the temperature to which the skin is exposed and how long it is exposed. The most common regulatory standard for the maximum temperature of water delivered by residential water heaters to the tap is 120 degrees Fahrenheit/48 degrees Celsius. At this temperature, the skin of adults requires an average of five minutes of exposure for a full thickness burn to occur. When the temperature of a hot liquid is increased to 140o F/60o C it takes only five seconds or less for a serious burn to occur1. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F /71-82o C, resulting in almost instantaneous burns that will require surgery. Since immediate removal of the hot liquid from the skin may lessen severity, splash and spill burns may not be as deep as burns suffered in a bathtub. High risk groups ¿¿ Older Adults Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults.2 Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. ¿¿ People With Disabilities or Special Need Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Mobility impairments, slow or awkward movements, muscle weakness or fatigue, or slower reflexes increase the risk of spills while moving hot liquids. Burns to the lap are common when a person attempts to carry hot liquids or food while seated in a wheelchair. Moving hot liquids can be extremely difficult for someone who uses a cane or walker. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person ' s intellect, perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. While the basic principles of scald prevention apply to the general population the additional concerns affecting these high risk groups must be addressed. Scald injuries result in considerable pain, prolonged treatment, possible lifelong scarring, and even death. Prevention of scald injuries is always preferable to treatment and can be largely accomplished through simple changes in behavior and in the home environment. Time and Temperature Relationship to Severe Burns4 Water temperature Time for a third degree burn to occur 155 F68o C 1 second 148o F 64o C 2 seconds 140o F 6 0o C 5 seconds 133o F 56o C 15 seconds 127o F 52o C 1 minute 124o F 51o C 3 minutes 120o F 48oC 5 minutes 100o F 37o C safe temperature for bathing During an interview on 3/3/16 at 2:35 p.m., the DON said she was not working in the facility when Resident #11 was burned and she had not seen anything in the building where residents were assessed for safe handling of hot liquids. She said she was unsure how the DM determined to cool the coffee to 135º for residents who drank coffee. During an interview on 3/3/16 at 2:40 p.m. the MDS coordinator said Resident #11 did not have an assessment regarding handling hot beverages. The MDS coordinator said she was not aware of any assessments determining if residents required assistance or required supervision when handling of hot liquids such as coffee. The MDS coordinator said she did not know how the DM determined that the coffee served at or below 135º would be safe. 2. Physician orders [REDACTED].#4, admitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. A quarterly MDS dated [DATE] indicated Resident #4 had severe cognitive impairment, unclear speech, rarely understood others, and was rarely understood. The resident was dependent on staff for locomotion, required extensive assistance of 2 staff to dress and extensive assistance of 1 staff for feeding. A physician progress notes [REDACTED].#4 had severe dementia, poor judgment and insight, was unable to offer complaints, and continued to have behavioral disturbances. Resident #4's care plan with the latest review date of 2/4/16, did not address his risk for ingestion of potentially toxic substances or the need to keep his environment free of those items he might ingest due to his cognitive impairment. Resident #4's care plan did not address the incidental ingestion of Peri Care that caused an emergency evaluation on 2/10/16. During an interview on 3/1/16 at 4:50 p.m., LVN A said she observed Resident # 4 around midnight on 2/10/16 to be sitting on the bedside with a cup containing a blue substance and noted an opened bottle of Peri Care at the bedside. She said the resident was sent to the ER. She said she did not document an incident report for Resident #4's possible ingestion of Peri Care and she could not remember if she notified the family concerning Resident #4 being sent to the ER. A nurse progress note dated 2/10/16 at 12:00 a.m., completed by LVN A indicated Resident #4 was found in his room holding a cup containing a blue liquid and a bottle of Peri Care was open at the bedside. The physician was notified and Resident #4 was sent by ambulance to the ER for an evaluation. An emergency transport booking form dated 2/10/16 at 12:30 a.m., indicated Resident #4 was transported to a local hospital. An emergency transport booking form dated 2/10/16 at 3:00 a.m., indicated Resident #4 was returned to the facility. A hospital ER discharge instruction dated 2/10/16 indicated Resident #4 had been treated for [REDACTED]. During an interview on 2/29/16 at 5:50 p.m., CNA H, said Resident #4 was found with an open bottle of Peri Care in his room on 2/10/16 on the bedside table within his reach. She said the DON in-serviced the staff to remove all items from reach of residents that were designated keep out of the reach of children, and place them in a plastic bag. She was unable to identify who left the bottle of Peri Care within Resident #4 ' s reach. CNA H said CNA B worked the night of 2/10/16. During an interview on 2/29/16 at 5:55 p.m., CNA B, said she worked the night of the incident on 2/10/16. The CNA said when she made her first round around midnight she found Resident #4 sitting on the bedside with a cup in his hand containing blue residue present in the bottom of the cup and an open bottle of blue colored Peri Care at the bedside. She said she did not know who had left the Peri Care within Resident #4's reach. She said she notified the charge nurse and the DON was called and Resident #4 was sent to the ER. CNA B said the DON provided an in-service after the incident on removing personal items from the bedside and put in a bag and place in a drawer. During an observation on 2/29/16 at 5:45 p.m., Resident #4 was sitting in the assisted dining room in a Geri-chair feeding himself and drinking from his cup. During an interview on 2/29/16 at 3:46 p.m. and 5:05 p.m., the DON said she could not remember which staff was on duty the night of 2/10/16 at midnight when Resident #4 was determined to have possibly ingested Peri Care. She said she believed the staff made an assumption Resident #4 drank the Peri Care because the bottle was open at the bedside. The DON said she did not have documentation of interviews or statements concerning Resident #4's incident on 2/10/16. The DON said she did not believe he drank the Peri Care because he was sent right back to the facility and the emergency room personnel said he had not ingested the Peri Care. During an observation on 3/1/16 at 9:50 a.m., Resident #4 was in the hall near the nursing station, attended by three staff members. The resident would rise from his Geri-chair and stand in a stooped position. During an interview on 3/1/16 at 2:06 p.m., Resident #4 ' s son said he was not notified of the incidental ingestion of Peri Care and did not know his dad was sent to the emergency department room on 2/10/16. During an interview on 3/2/16 at 11:00 a.m., the administrator said he expected nursing staff to write an incident report if Resident #4 was suspected to have ingested Peri Car. He said the incident should have been fully investigated especially since the resident had dementia. He said he would have notified the state agency, and would have in-serviced staff on accident prevention and hazards. A Material Safety Data Sheet dated January 30, 1991, indicated Peri-Care appeared light blue-green oleaginous semi-solid and was not considered a primary skin or eye irritant or toxic by oral ingestion. During an interview on 3/2/16 at 11:08 a.m., the administrator said he expected a full investigation of injuries to residents that were not witnessed and would provide staff training and follow up and report to the state agency. A nursing policy and procedure for reporting incidents to the state and home office with a revision date 1/8/07 indicated burns and any hospitalization s resulting from an injury or unusual occurrence would be reported to the facility Risk Manager within 24 hours. An incident report would be written containing the resident injury and all facts and environmental factors surrounding the variance. Notify the physician and family member or legal guardian of all injury reports. Report Neglect Allegations: report serious accidental injury that results from a facility practice action/inaction by staff, incidents that are suspicious in nature or circumstances within the facility. Conduct or conditions that may be associated with neglect, abuse, or exploitation and result in serious injury must be reported to the state agency within 24 hours. An Abuse/Neglect policy and procedure dated 1/8/03 indicated the facility will provide and ensure the promotion and protection of resident rights. It is each individual ' s responsibility to recognize report and promptly follow up abuse or neglect allegations or suspicion of abuse or neglect, and situations that may constitute abuse or neglect to any resident in the facility. Neglect defined as a failure to provide essential needs or protection for a person incapable of providing for him/herself independently or harming or threatening with harm; can be committed by self or other. Prevent, identify, investigate, and protect The administrator and DON were notified on 3/3/16 at 3:23 p.m, that an Immediate Jeopardy situation was identified due to the above failures. The facility's Plan of Removal was accepted on 3/3/16 at 8:15 p.m. and included: 1. Facility failed to monitor coffee temperature to avoid burns and failed to supervise resident getting coffee. Facility failed to identify those Residents at risk for injury self- serving and drinking coffee. Coffee temps at the time of this incident were at temperatures that could cause burn injuries. (Registered Dieticians) recommends coffee to be served at 130-135 degrees to prevent burns. 2. We acknowledge that a resident was burned with coffee on 11/16/15. This Resident did not report burn until 11/17/15. An assessment, treatment, investigation and self-report to DADS should have been completed. The facility failed to assess and provide treatment in a timely manner. The facility failed to notify Physician. This is an unacceptable practice. An in-service was conducted on 03/02/16 on abuse, neglect, misappropriation and when, how and who to report to. Also the 03-02-16 in-service covered how to use the STOP and Watch tool to recognize changes of condition. All staff will be in-serviced on recognizing hazards and when to report incidents by DON on 3/4/16. (Administrator) will in-service (DON and ADON) on when and how to self-report incidents to DADS 3/4/16. Nursing staff will be in-serviced on assessment and notification of physician by DON on 3/4/16. 3. Coffee has been moved into the kitchen. Kitchen staff, specifically the dietary aide will ensure coffee is proper temperature prior to serving coffee. Clip board will be kept next to coffee pot and when temperature reaches 130 degrees, staff will initial, date and time it. They will check coffee every 10 minutes until appropriate temperature of 130-135 F degrees is reached. 4. Signs will be placed at both kitchen doors that state Please ask for coffee. 5. Resident counsel president and frequent coffee drinkers met with (administrator) to discuss plan to move coffee into kitchen for resident safety and have agreed with the plan. 6. Staff will be in-serviced by 3/4/16 that coffee has been moved into the kitchen and it must be asked for due to the hazards of burns from hot liquids and the temperature of the coffee should not exceed 135. 7. Dietary staff have been in-serviced by (dietary manager) on the reason to move coffee into kitchen and that it must be available at all times while kitchen is open. Action plan that is currently in place has dietary staff cooling coffee to 130- 135 F degrees before serving. As of this time there have been no complaints about coffee temperature and no injuries since coffee has been being monitored and served at the new lower temp of 130-135F. 8. All residents that have the ability to drink coffee (take fluids/nutrition by mouth) will be assessed for safe handling of hot liquids by nursing and therapy staff by the completion of noon meal on 3/4/16. After completion of assessments, appropriate interventions will be put in place, eg; (cup with lid, drink beverage only at a table, staff to assist resident with hot beverages, wear splint if indicated, resident to wear clothing protector) On 03/04/16, the surveyors confirmed the Plan of Removal had been implemented sufficiently to remove the Immediate Jeopardy by: During interviews 4 CNAs said they were in-serviced and informed staff was responsible with obtaining coffee from the kitchen staff, assisting residents with transporting of the hot liquids and they were to monitor the residents for safe handling of hot liquids. The CNAs indicated they were told a list of residents with cognitive impairment requiring supervision and assistance was located at the nursing station. The 4 CNAs said they were in-serviced to keep all personal care items out of reach of cognitively impaired residents and any items that indicated keep out of the reach of children should be removed and stored in cabinets. All were familiar with the facility abuse/neglect policies and procedures, and none were aware of any abuse/neglect in the facility. All knew what steps to take if they became aware of abuse issues, concerning protection, reporting, and prevention. During interviews the DON and ADON said all staff present at the facility and prior to coming on duty was in-serviced regarding the new policy for providing hot liquids, safely transporting and monitoring residents for the ability to safely drink/handle. The DON and ADON said nursing staff were in-serviced regarding a hot liquid safety evaluation to be performed on admission, re-admission, and quarterly and with significant changes. They both indicated staff was also informed to keep all personal care items secured. The DON and ADON said they had received in-service for investigating incidents and reporting to the state agency. During interviews with the DM and 1 kitchen staff said they removed the coffee dispenser from the dining room and were instructed not to allow any resident to obtain their own coffee. They were to monitor the temperature of the coffee assure it was maintained between 130º-135º prior to serving. They had a list of residents who could not drink coffee unsupervised and were instructed that they could not provide the coffee unless the impaired resident was supervised. During interviews 3 nurses reported being in-serviced on completing hot liquid safety evaluations, staff should be monitoring all residents for safety of handling hot liquids, no personal care items should be available to residents and cognitively impaired residents monitored to ensure no personal care items are within reach. During interviews with 3 frontline supervisors, all were familiar with the facility abuse/neglect policies and procedures, and none were aware of any abuse/neglect in the facility. All knew what steps to take if they became aware of abuse/neglect issues, concerning protection, reporting, and prevention. All were aware of their duty to monitor staff, and report and intervene as needed. On 3/4/16 at 6:36 p.m., the administrator and DON were advised the Immediate Jeopardy was removed, but the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. The CMS 672 dated 2/29/16 indicated 28 residents were identified with cognitive impairment and an undated list indicated 7 residents frequently drank coffee