Every finding on record at Ashton Medical Lodge

Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 nurse medication carts reviewed for medication storage and for 2 of 4 nurse medication carts (hall 1 cart and hall 4 cart) observed for medications stored and properly labeled. LVN A failed to ensure her nurse medication cart was secured when it was left unattended on [DATE]. The hall one nurse medication cart had one insulin pen that belonged to Resident #100 that had been opened but not dated when it was placed into use. This these failures could place clients at risk for drug diversion or accidental ingestion and could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included: Unlocked and unattended medication cart. Observation and interview on [DATE] at 09:55 AM the nurse medication cart for hall 5 was seen unlocked and unattended for at least 10 minutes. The cart was parked in the hallway and there were no staff that were supervising it. LVN A passed by the nurse medication cart and did not notice the cart was unlocked. LVN A then came back to the cart and was in the process of unlocking the cart. The LVN was told that the medication cart had been unlocked and unsupervised for at least 10 minutes. LVN A said she normally locked her cart when she stepped away but had forgotten to lock it. Observation of the items inside the medication cart revealed several insulin pens and other medications. The LVN said that leaving the cart unlocked could give access to unauthorized people that could have opened the medication cart including residents. Interview on [DATE] at 11:42 AM ADON G said the medication carts were expected to be locked if unattended. The ADON said LVN A should have locked the medication cart when she stepped away. ADON G said she would monitor the medications carts on a daily basis when she was there. The ADON said possible negative outcomes could be that another resident can have access to the medications in the cart. ADON G said that family members or unauthorized staff could also have access to the unlocked medication cart. Interview on [DATE] at 3:22 PM, the DON said the nurse medication carts were expected to be locked when unattended. The DON said that they conducted rounds throughout the day to ensure that the nurses were following procedures. The DON said that possible negative outcomes could be that anybody could have access to the cart including residents that might get something from the cart. Interview on [DATE] at 3:30 PM, the Administrator said it was expected for the nurses to lock their medication carts when they were away from the cart. The Administrator said if the medication cart was left unlocked and unattended then there was a possibility of residents opening the drawers and taking some of the medications. Expired and undated insulin pens. Review of Resident #100's admission record dated [DATE] revealed she was admitted to the facility on [DATE] with diagnosis of diabetes type 2. She was [AGE] years of age. Review of the current care plan for Resident #100, last reviewed/revised: [DATE], revealed in part: The resident had diabetes. Fiasp FlexTouch Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: subcutaneously (Under the skin) at bedtime for type 2 diabetes. Review of Resident #100's physician orders dated [DATE]. Fiasp FlexTouch Subcutaneous Solution Pen-injector 100 UNIT/ML (Insulin Aspart) Inject as per sliding scale: if Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals and at bedtime for type 2 diabetes. Observation and interview on [DATE] at 11:38 AM of the nurse medication cart for hall 1 was checked with RN B present. Inside the cart was an insulin pen that belonged to Resident #100 that had been opened but had no open date found on the pen. RN B said it was usually each nurses responsibility to date the insulin pens when they were first opened so that they would know when the pen expired. RN B said if the pen was not dated when opened then how would they know when it was expired. RN B said she did not know who had opened that insulin pen. Interview on [DATE] at 11:44 AM ADON G said the nurse managers would check the nurse medication carts to check if there were any opened medications, that they were dated when opened. ADON G said the insulin should have been removed from the cart. ADON G said a possible negative outcome could be that the medication could not cause the desired effect. Interview on [DATE] at 2:24 PM with ADON F said it was the responsibility of each nurse to check for expired on undated insulins in the nurse medication carts. The ADON aid she did random checks of the nurse medication carts. ADON F said if an insulin was not dated then the staff would not know when it was expired. The ADON said if the insulin had expired then it could possibly have led to the medication not causing the effect of what it was meant to do. ADON F said once the insulin pen was opened they were usually good for 28 to 30 days and then it would expire. Interview on [DATE] at 3:36 PM, DON said it was expected for the nurses to check the medication carts when they took their cart. The DON said they would check the nurse medication carts at random times. The DON said if an insulin had no open date then there was a possibility that the medication would not cause the desired effect. The DON said an opened insulin was good for 30 days after it was opened. Interview on [DATE] at 3:40 PM, the Administrator said it was expected for nurses to date the insulin pens when they opened them. Review of the facility's undated policy titled Medication Cart indicated in part: To administer medication more quickly and efficiently. If the cart is left at any time during medication pass due to an emergency, it must be locked. Record review of the Fiasp insulin pen manufactures pamphlet date 2025 indicated in part that the insulin was good for 28 days after opening. Review of the Humalog insulin pen manufactures pamphlet date 2026 indicated in part that the insulin was good for 28 days after opening. Record review of the facility's undated document titled Insulin med administration indicated in part: Med cart no missing or expired supplies, items dated when opened. Obtain pen device or vial date vial/pen after first use if required.

Based on observation, interview, and record review the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for 1 of 7 residents (Resident #51) reviewed for respiratory care in that: Residents #51's oxygen nasal cannula tube was not bagged when not in use. This failure could place the residents at risk of infection. Findings included: Review of Resident #51's admission record, dated 04/09/2026, indicated she was admitted to the facility on -05/10/2024 with diagnoses of lack of coordination and muscle weakness. She was [AGE] years of age. Review of Resident #51's physician order report dated 04/09/2026 indicated in part: Oxygen - continuously = Oxygen at 2L/PM via nasal cannula continuously. Check every shift. Check O2 sats Q shift and keep O2 at or greater than 92% Record O2 sats every shift. every shift related to heart failure. Review of Resident #51's care plan revised on 04/02/2026 indicated in part: The resident is at risk for alteredrespiratory status/difficulty breathing r/t recent surgical procedure. The resident will have no signs and symptoms of poor oxygen absorption through the review date. Respiratory therapy: Complete respiratory assessment and document findings and interventions Q Shift. Review of Resident #51's annual MDS dated [DATE] indicated in part: BIMS of 8 indicating the resident was moderately impaired. Respiratory treatments - Oxygen therapy. Observation and interview on 04/09/2026 at 9:04 AM revealed Resident #51's oxygen nasal cannula on the bed and not stored in a bag which was located on the oxygen concentrator machine. Resident #51 was seen sitting up in her wheelchair awake and alert. The resident was wearing an oxygen nasal cannula that was connected to an oxygen tank that was located on the back of the resident's wheelchair. Resident #51 said she had not placed the oxygen nasal cannula on the bed and that the staff who had helped her out of bed were probably the ones that placed it there. Observation on 04/09/2026 at 10:08 AM Resident #51's oxygen nasal cannula's was observed resting on the wheelchair and not stored in a bag which was located on the back of the wheelchair. Observation and interview on 04/09/2026 at 10:42 AM revealed Resident #51 was in her bed awake and alert. The resident said she had not placed the oxygen nasal cannula on the back of the wheelchair. Resident #51 said the staff that had assisted her to her bed were the ones that must have placed it there. Interview on 04/09/2026 at 10:48 AM CNA D said he had assisted Resident #51 into her bed. CNA D said he had placed Resident #51's oxygen nasal cannula on the back of the wheelchair and had not stored it on the bag as he should have. CNA D said if the oxygen nasal cannula was not stored in the bag it could lead to infections as the oxygen nasal cannula could get contaminated Interview and observation on 04/09/2026 at 1:42 PM Resident #51 was in her room, in bed awake and alert. The resident said the staff were the ones that removed the oxygen nasal cannula from her. Resident #51 said she had not removed the oxygen nasal cannula herself and left it to the staff to do that. Interview on 04/09/2026 at 4:34 PM ADON F said whenever a resident was not using the oxygen nasal cannula it was supposed to be stored in the bag. The ADON said that if the oxygen nasal cannula was not stored in the bag and left out that could lead to possible respiratory infections to the resident using them. Interview on 04/10/2026 at 3:22 PM, the DON said it was expected for the oxygen nasal cannulas to be stored in the plastic when hot in being used. The DON said if the cannulas were not stored in the bag it could cross contamination and respiratory infections. The DON said the policy provided regrading storage of the oxygen nasal cannula did not indicated how it should be stored when not in use but that was the only policy they had. Interview on 04/10/2026 at 3:34PM, the Administrator said it was expected for the oxygen nasal cannulas to be stored in the bags. The Administrator said if the cannulas were not stored it could possibly lead to some form of infection. Record review of the facility's undated policy titled Administration of cannula did not indicate about how to store the cannula when not in use. (There was no indication of how the cannula should be stored).

Based on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #64) reviewed for transfers. CNA H and CNA I performed an incorrect two-person transfer on Resident #64 on 4/6/26. This failure could place residents who required assistance during transfers at risk of pain and injury. Findings included:Record review of Resident #64's admission Record, dated 4/8/26, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia, arthritis, weakness, and abnormalities of gait and mobility. Review of Resident #64's Quarterly MDS Assessment, dated 2/6/26, revealed:She had a BIMS score of 3 of 15 (indicating severe cognitive impairment)She needed substantial assistance with transfers. Review of Resident #64's Care Plan, last updated 4/6/26, revealedFocus: Resident requires assistance with late loss ADL's and use of wheelchair for locomotion/2-person transfer and able to use sit to stand [lift].Interventions included: 12/23/25 May use sit to stand for transfers and Resident is a 2-person assist any use sit to stand with transfers. Revised 4/6/26.Focus: Limited range of motion related to functional mobility, revised 9/16/24.Interventions included May use sit to stand for transfers, initiated 9/5/25. Review of Resident #64's Order Summary Report, dated 4/8/26, revealed order stated 12/13/25 May use Sit to Stand for Transfers. Review of the electronic ADL flow sheets on 04/08/20 for April 2026 the CNAs revealed a Sit to Stand Lift was indicated. Observation of a two-person gait-belt transfer on 04/06/2026 at 1:57 PM revealed CNA I locked Resident #64's wheelchair. CNA I placed the gait belt around Resident #64. CNA I hooked her arm under Resident # 64's arm/shoulder and held the gait belt behind Resident #64. CNA H hooked her arm under Resident #64's arm/shoulder and grabbed the back of Resident #64's pants. On the count of three, the aides assisted Resident #64 to stand and pivot onto the bed. Resident # 64 complained of pain by yelling ow ow ow. The aides positioned Resident #64 in bed and Resident #64 stated she no longer hurt. Interview on 4/06/2026 at 2:57 p.m. Resident #64's RP stated Resident #64 always complained of pain when transferred. The RP stated Resident #64 had as-needed pain medication but Resident #64 only complained of pain during transfers when the aides hooked under her arms. The RP stated all the aides hooked under the arms but did the transfer differently. The RP said once the pulling on the arms went away, Resident #64 quit hurting. The RP stated it was due to the diagnosis of arthritis, and she did not have diagnosis of osteoporosis. Interview on 04/08/2026 at 2:12 PM CNA I stated she worked at the facility for 13 months. CNA I said she thought the transfer went pretty well. CNA I said it was not unusual for Resident #64 to complain of pain during a transfer. CNA I said during the transfer she did hook her (CNA I) arms under Resident #64 and grabbed the gait belt. CNA I said Resident #64 could bear weight. CNA I said Resident #64 always said ow, ow, ow on transfers and had pain in her shoulders. CNA I said they would let the nurses know and she did not know if anything happened after that. CNA I said Resident #64 had pain in her shoulders. CNA I said Resident #64 complained of pain worse while using the sit to stand lift. CNA I said she trained to do a two-person gait belt transfer by putting the gait belt on, one person stood on each side of the resident and hooking their arms under the resident. CNA I said the lead CNA would check on the aide's skills pretty often, but a nurse had never done a skill check off with her. Interview on 04/08/2026 at 2:54 PM CNA H stated she worked at the facility as an as-needed CNA for three years. CNA H stated Resident #64 used to help with transfers a lot more. CNA H stated Resident #64 said she was hurt and could not do the transfer and was weak and scared. CNA H stated Resident # 64 was always a two-person transfer. CNA H said she would use the sit to stand lift with Resident # 64, but Resident # 64 complained it made her arms hurt and preferred the two-person transfer. CNA H stated when she did a transfer, she preferred to leave the wheelchair unlocked because it was easier to move out of the way, but CNA I locked it. CNA I stated when CNA I told Resident #64 she was going to transfer her, Resident #64 said she was afraid and it hurt while transferring, but Resident #64 always did that. CNA I said Resident #64 would get confused and think the aides put her on the floor, but the RP would reassure Resident #64. CNA I said Resident #64 received pain medications and transferring her was stressful because the aides did not want to hurt her. CNA I said she hooked her arm under Resident #64's arm and grabbed Resident #64 pants. CNA I said she always grabbed a resident's pants. CNA I said if someone pulled up on the pants it would give the person a wedgie. CNA I stated it did happen to some people. CNA I said a wedgie would not be comfortable especially with a brief on. Interview on 04/08/2026 at 3:44 PM the PTA stated the facility had periodic in-services on transfers. The PTA said the staff would come into the therapy room and the therapy department would show the staff body mechanics with a gait belt. The PTA said the therapy department trained the staff to do a two-person gait belt transfer by placing the gait belt snugly on the resident, position the wheelchair as close to where the resident was being transferred to, lock the brakes and preferably remove the wheelchair arms. The PTA said the staff should then stand in front of and to the side of the resident, hold the gait belt, count to three, help the resident stand and pivot. The PTA said the consequences of an under-arm transfer was the risk of shoulder dislocations, skin tears or pain. The PTA said this was covered during in-services. The PTA said she had previously worked with Resident #64. The PTA said Resident #64 was pleasantly confused, was able to bear weight, and able to follow simple one-step instructions. The PTA said Resident #64 thought she could not bear weight, but she could. The PTA said the observed transfer was not a correct transfer because the staff hooked their arms under Resident #64's, and they should have held onto the gait belt. The PTA said holding the pants increased the risk of skin shearing (a specific type of skin tear). The PTA said the last training the therapy department did was about 9 months. The PTA said she did not do skill checkoffs about transfers with the staff. Interview on 04/08/2026 at 4:07 PM the DON stated her expectation for a two-person gait belt transfer was to let the resident know what the staff were doing, place the belt on the resident and have a second person. The DON said staff should hold onto the belt because that was what it was there for. The DON said she expected the staff to hold the gait belt on the sides or the back, count to three and move the resident. The DON stated hooking under the arms or grabbing a resident by the seat of the pants was not ok. The DON said holding a resident under the arm could dislocate the arm. The DON stated grabbing a resident by the seat of the pants did not provide a secure grip on the resident. The DON described Resident #64 as having an order for a sit to stand but could be a two-person transfer depending on how Resident #64 was doing. The DON stated sometimes Resident #64 could transfer herself, but the facility had her identified as a two-person transfer due to Resident #64's fall risk. The DON stated Resident #64 fluctuated between a two-person transfer and a sit to stand lift. The DON stated if a Resident complained of pain, she expected the aides to stop as soon as it was safe to do so and address the pain. The DON stated she expected the aides to get Resident #64 positioned and if Resident #64 still complained of pain to get the nurse. The DON stated the facility did a proficiency check on hire during orientation and if there were issues, they would do education with that specific aide. The DON stated aides had proficiency checks each year. The DON stated she thought the last in-service was a month prior to the survey.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services for 1 (Resident #8) of 1 resident reviewed for expired medications. The hall four nurse medication cart had one insulin pen that belonged to Resident #8 that had expired. This these failures could place clients at risk for drug diversion or accidental ingestion and could place residents at risk of receiving medications that were expired and not produce the desired effect. Findings included:Review of Resident #8's admission record dated 04/08/2026 revealed he was admitted to the facility on [DATE] with diagnosis of diabetes type 2. He was [AGE] years of age. Review of the current care plan for Resident #8, last reviewed/revised: 06/12/2025, revealed in part: The resident had diabetes. Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals for diabetes. Review of Resident #8's physician orders dated 04/08/2026. Humalog KwikPen Subcutaneous Solution Pen injector 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale subcutaneously before meals for diabetes. Observation and interview on 04/08/2026 at 11:50 AM the nurse medication cart for hall 400 was checked with LVN C present. Inside the cart was an insulin pen that was dated as opened on 02/26/26 which belonged to Resident #8. LVN C said she had not noticed that the insulin pen had expired and that Resident #8 hardly required insulin. LVN C said the insulin pen was good for 30 days after they were opened. LVN C said it was each nurse's responsibility to check for expired insulins. LVN C said a negative outcome could be that the insulin may not be as effective as it should be if it was expired. Interview on 04/10/2026 at 11:44 AM ADON G said the nurse managers would check the nurse medication carts to check if there were any expired medications had been removed. The ADON was made aware of the observation of an expired insulin pen in one of the nurse medication cart used for hall 4. ADON G said the insulin should have been removed from the cart. ADON G said a possible negative outcome could be that the medication could not cause the desired effect. Interview on 04/10/2026 at 2:24 PM with ADON F said it was the responsibility of each nurse to check for expired on undated insulins in the nurse medication carts. The ADON aid she did random checks of the nurse medication carts. The ADON said if the insulin had expired then it could possibly have led to the medication not causing the effect of what it was meant to do. ADON F said once the insulin pen was opened they were usually good for 28 to 30 days and then it would expire. Interview on 04/10/2026 at 3:36 PM, DON said it was expected for the nurses to check the medication carts when they took their cart. The DON said they would check the nurse medication carts at random times. The DON said if an insulin had expired then there was a possibility that the medication would not cause the desired effect. The DON said an opened insulin was good for 30 days after it was opened. Interview on 04/10/2026 at 3:40 PM, the Administrator said it was expected for nurses to date the insulin pens when they opened them. The Administrator said if an insulin pen had expired then there was a possibility of some sort of negative effect or it may not do what it was meant to do. Record review of the facility's undated document titled Insulin med administration indicated in part: Med cart no missing or expired supplies, items dated when opened. Obtain pen device or vial date vial/pen after first use if required.

Based on observation, interview and record review, the facility failed to ensure one Resident (Resident #16) of two reviewed for Percutaneous Endoscopic Gastrostomy (PEG-a tube inserted through the abdomen into the stomach for the purpose of administering liquid nutrition and medications) received the appropriate treatment and services to prevent complications and aspiration. LVN E failed to check PEG tube placement by auscultating (Listening with stethoscope) and checking for residual prior to administering Resident #16's medication as ordered by the physician. This failure placed residents who had a PEG tube at risk for complications, aspiration, and pneumonia. Findings include.Record review of Resident #16's admission record dated 04/07/2026 revealed she was admitted to the facility on [DATE] with diagnosis of gastrostomy status (Gastrostomy status indicates that a person has a surgically placed tube providing direct access to the stomach for nutrition, hydration, or medication). She was [AGE] years of age. Record review of the current care plan for Resident #16, last reviewed/revised: 03/26/2026, revealed in part: The resident requires tube feeding. The resident will remain free of side effects or complications related to tube feeding through review date. HOB elevated 30-45 degrees at all times. Check tube placement prior to each feeding, meds and fluids per auscultation and residual Q shift. If 100cc, HOLD feeding. Record review of Resident #16's physician orders dated 04/09/2026 revealed: HOB elevated 30-45 degrees at all times. Check tube placement prior to each feeding, meds and fluids per auscultation and residual Q shift. If 100cc, hold feeding. Start date 04/01/2026. Observation on 04/09/2026 at 12:25 PM revealed LVN E administered Resident #16's medication Loperamide via the residents PEG tube. LVN E poured 30ml of the Loperamide medication into a medication cup then entered Resident #16's room. LVN E then took a syringe and used it to pour some water into the resident's PEG tube and flushed it. LVN E then took the 30ml cup of Loperamide and poured it into the resident's PEG tube. LVN E then finally flushed the PEG tube with some more water and was done with the medication administration. LVN E did not check for tube placement prior to the medication administration. Interview on 04/10/2026 at 11:36 AM LVN E said she had gotten nervous and forgotten to check Resident #16's PEG tube placement before she administered the medication. LVN E said if PEG tube placement was not checked then it was possible the tube was not in the right place and the medication could go in the wrong area instead of the stomach. Interview on 04/10/2026 at 11:40 AM ADON G said LVN E should have checked for PEG tube placement before she administered the medication. The ADON said a possible negative outcome could be that the PEG tube would not be placed where it was supposed to be and it could have led to the medication not going to the right area. Review of the facility's undated policy Tube medication administration indicated in part: To safely and accurately administer medications to residents who receive their entire oral intake via enteral feeding tube. Procedure: confirm physician order. Place each medication in a separate cup. Check for correct placement of tune by injecting air and listening with stethoscope to abdomen. Unclamp tube and use either one of the following procedures Insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds or aspirate stomach contents with a syringe.

Based on interview and record review, the facility failed to ensure the right to be free from abuse was provided for 1 (Resident #1) of 15 residents reviewed for abuse, in that: The facility failed to protect Resident #1 from abuse on 4.24.25 when Resident #1 was handled roughly by CNA A. These failures could place residents at risk of abuse, injury, intimidation, fear, agitation, and psychological harm. Findings included: Resident #1 was an [AGE] year-old female admitted to the facility on 1.24.22 with diagnoses of lack of coordination, urinary tract infection, anxiety disorder, and type 2 diabetes mellitus. Resident #1's quarterly BIMS status was completed on 4.9.25 with a score of 5, indicating severe cognitive impairment. Record review of CPS report dated 4.24.25 indicated PRIMARY CONCERNS: Today was 04/24/2025, MF contacted LA. MF stated NR was being aggressive CL. MF took off CLs shirt aggressively and grabbed her by the waste and was placed on the bed making a sound. NR was able to observe the incident through a curtain and saw a shadow of what happened. It was unknown if CL has any injuries. NR stated CL was very combative when female nurses try to assist her. It was unknown what was the name of the MF that physically abused CL. NRs in the facility are investigating the incident. IP stated that NR has been suspended. There was no video of the incident. NR that witnessed that incident did not have a clear view of the incident. It was unknown if this was the first time this has happened. CL does get combative with NRs in the facility. Record review of statement given by CNA A dated 4.24.25 regarding incident indicated involving Resident #1: I CNA A was laying down my resident per usual she was fighting as being on the hall 200 I know the resident very well so it didn't alarm me while I was taking resident jacket off resident started to yell and hit, per usual like I said the resident was known for this behavior as I do chart in every night I work when the behavior happens. As I got her jacket off, resident stared to kick and continue to call me names. As I got read to transfer my resident, I talked clear on what I was doing and letter her know it was not ok to kick me while I got resident on bed after transfer and resident attempted to kick me again I spoke loud and clear it wasn't ok to kick and told her she was wet and needed to be changed as I got ready to take residents pants off I stopped because my curtain was not shut all the way while I stopped to close the curtain I see a housekeeper watching me. As I continue to change my resident I spoke loud and clear on everything that I was doing. Attempted to contact CNA A on 5.14.25 at 9:16 a.m., with no answer. Voicemail message with call back information was left. During an interview on 5.14.25 at 1:55 pm HK B stated that she normally works 8-5pm Monday through Friday at the facility. She stated that the night of the incident she was called in to help and was working 6p to 9p. she stated she was cleaning the room and noticed behind the curtain that an aid was changing resident. She stated Resident #1 was not very verbal, but that night Resident #1 was saying the words, No and Stop, which caught her attention. She stated that she saw the aid through the curtain removed the resident's shirt by pulling the resident forward and hunching her over and yanking off the shirt. She stated that when the shirt came off the resident slammed back into the wheelchair. She stated that CNA A then picked up Resident #1 out of the wheelchair and slammed Resident #1 down on the bed roughly, shaking the bed. She stated she was shocked/stunned and was not sure what to do. She stated she went and reported what she had seen to the charge nurse at the time. Record review of statement by HK B regarding incident dated 4.24.25 indicated: I was standing at 200 hall showers getting ready to clean it when I heard Resident #1 yelling. When I looked up at her room, I saw the back of Resident #1 chair and part of Resident #1 back. I watched someone aggressively taking off her shirt and throw it on the floor at the end of her bed. Resident #1 was continuously loudly yelling to stop. Then I saw the shadow get closer to Resident #1 and aggressively put her on the bed. The aide looked around the curtain and made eye contact with me. That's when I saw that the aide in the room was CNA A. Once CNA A saw me staring at her she closed the curtain more and began speaking extremely loud at Resident #1 to stop hitting her. Which CNA A was not saying before she saw me. Even though there was a curtain I could still see shadows and I never saw Resident #1 striking out. I stayed where I was until CNA A left the room. Administrator was notified immediately. During an interview on 5.14.25 at 10:45 am Resident #1 was unable to communicate any answers to investigator. Resident #1 only made noises towards investigator when asked questions. During an interview on 5.15.25 at 2:30 pm DON stated that this was more of a resident right then an abuse case because she stated the witness was in the shower room not in the room. She stated she has no idea if the witness was in the room. She stated that CNA A should have stopped what she was doing when Resident #1 told her no and stated stop. She stated CNA A should have gone and got help at this point or left the room and returned later to assist Resident #1. During an interview on 5.15.25 at 4:20 pm administrator stated he received a call on 4.24.25 at roughly 7:15 pm that CNA A had been seen by another employee being aggressive and rough with Resident #1. He stated that CNA A was suspending immediately, and he started his investigation. He stated that his investigation was targeted for resident rights issue, not abuse, but he stated that CNA A should have stopped working with Resident #1 when Resident #1 told her no and stop. Record review of in-service dated 4.16.25 titled abuse/neglect indicated: Abuse Coordinator (administrator). Abuse must be reported immediately to the abuse coordinator. Record review of facility Abuse/Neglect policy, undated, reflected the following: Each resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Mental abuse includes, but was not limited to, abuse that was facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident, contractors, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals.:

Based on observation, interview, and record review, the facility failed to ensure the resident's right to be free from misappropriation of resident property for 1 of 16 residents (Resident #3), reviewed for drug diversion. The facility failed to prevent the misappropriation of an unknown number of Resident #3's Lorazepam Oral Concentrate 1MG/0.5ML (Controlled Substance requiring double lock and count every shift) on 08/03/2024 from the medication cart that was never found. This failure could place residents at risk of misappropriation, and could result in increased pain, and poor quality of life. Findings included: Review of Resident #3's face sheet revealed a [AGE] year-old female admitted to the facility on 10.31.23 with the diagnoses of fracture of sacrum, pressure ulcer of sacral region, dementia, and anxiety disorder. Resident #3's quarterly BIMS status was completed on 4.28.25 with a score of 1, indicating severe cognitive impairment. Review of Resident #3's Comprehensive Care Plan last revised 10.20.24, revealed: Focus: Pain/Pain Management. Administer pain medications as ordered. Describe pain scale used and location of pain and any pain behaviors observed. Review of Resident #3's electronic physician orders revealed: Lorazepam Oral Concentrate 1MG/0.5ML give 0.75 ml by mouth every 3 hours as needed for Anxiety, order date 3.20.25. Record review of Packing Slip dated 4.15.25 indicated: Controlled Substances, for Resident #3, Lorazepam 2mg/ml. Signed by LVN C. Review of the provider investigation report dated 4.18.25 revealed facility investigation findings confirmed misappropriation of property and drug diversion. On 4.15.25 the lorazepam was never found, facility unsure of its whereabouts. Nursing staff educated on control medication storage double lock system. Facility found that a control medication was not in a double lock system due to it being broken and the narcotics were not counted correctly. Resident never went without meds. Record review of in-service dated 4.18.25 titled medication room indicated: if you are not a licensed/certified to handle medications you can not go into the medication room. Record review of Resident #3's MAR dated 4.13.25 through 4.21.25 indicated Lorazepam Oral Concentrate 1MG/0.5ML was not given any day due to no pain notated by Resident #3. Attempted to contact LVN C on 5.15.25 at 4:05 pm, no answer, left message. During an interview on 5.14.25 at 1:20 pm ADON stated all nurses and medication aides have access to the medication room and there are only 2 keys to the lock box in the refrigerator. She stated one key was on the 100-hall key ring and the DON has a key. Observation of lock box on 5.15.25 revealed no medications at this time. During an interview on 5.14.25 at 3:00 pm DON stated medications delivered on 4.15.25, LVN C signed for the medications which came in in bottle, LVN C put medication in refrigerator in medication room not in lock box. She stated LVN C couldn't get lock box open. She stated the medication was not missed until a few days later. She stated the Resident #3 never missed any doses because the medication was as needed for pain. She stated this was missed through multiple narcotic counts. She stated all medication aides and all nurses had access to the refrigerator. She stated only 1 key to lock box. She stated 1 CMA, and 2 nurses have access to hall 300 medication cart, and she did not see any concern with that. She stated the nurse do the oncoming narcotic count and the ongoing narcotic count. During an interview on 08/15/24 at 03:20 PM, the Administrator stated was expectation was to not have any medication errors and for staff to follow protocol and policies when administering medications. The Administration stated was DON and ADON oversaw overseeing medication errors and properly signing and counting narcotics. Record review dated 4.18.25 titled confidential employee corrective action form signed by LVN C indicated: Not counting narcotics per policy and procedure. Request for policy from Administrator and DON for Controlled Substances was requested on 5.15.25 at 4:35 pm. The policy was not provided by the time of exit.

Based on interviews and record reviews the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated, for 1 (Resident #4) of 8 residents reviewed for investigating alleged verbal abuse. On Tuesday 4.15.25 Resident #4 reported that she was hit by an employee at night. The Facility did not investigate the allegation of physical abuse. The failure could place residents at risk for abuse. The findings included: Resident #4 was an [AGE] year-old female admitted to the facility on 10.30.20 with diagnoses of Parkinson's disease, hypertension, dementia, and chronic pain. Resident #4's quarterly BIMS status was completed on 4.28.25 with a score of 7, indicating moderate cognitive impairment. Record review of facilities incident report dated 4.15.25 at 9:00 pm indicated: Resident states that she was hit by an employee last night. She was unable to give a name or description of an alleged perpetrator. During an interview of Resident #4 on 5.15.25 at 3:45 pm Resident #4 stated she did not remember the incident and does not remember being hit by anyone. Progress note dated 4.16.25 at 5:13 pm indicated: Note Text: This WCN completed skin assessment today on resident d/t DON reporting that an allegation was made by resident. Resident skin warm/dry. Turgor WNL. NPE noted to BLE. Resident has no new open areas to note. Skin against bony prominences remains intact. Resident has no bruising throughout body at this time. This nurse observed redness to bilateral buttocks, which barrier cream was given to CNA staffing to apply Q brief change. Reported findings to resident, advising no bruising noted, however will be continued to be monitored for any latent bruising. During assessment, the resident voiced concerns of staff member being too rough and rushing me and stated in the shower, she experienced rough care from same staff member. She also included that she believed staff had bruised her buttocks, however, this nurse advised she currently has no bruising present to buttocks. This nurse reported findings to ADON, LVN, DON, RN/BSN. Attempted to contact WCN D on 5.15.25 at 2:05 pm, no answer, left message. During an interview on 5.15.25 at 3:00 pm DON stated that the only employee that matched the identity of any nurse working the night of 4.15.25 was LVN C. She stated but after interviewing Resident #4 and that the resident could not give any identifying features of the nurse, the investigation was completed. She stated no employee was suspended during the investigation. She stated LVN C was not suspended because she was off work the next two days anyways. She stated she did not know about the progress note dated 4.16.25. DON stated knowing that information she would have suspended LVN C and done a more through investigation. She stated she felt the facility did do a through investigation but based on the documentation provided in the investigation, it was not very thorough. During an interview on 5.15.25 at 4:20 pm Administrator stated that due to Resident #4 not being able to identify anyone there was not much they could do. He stated he did not know about the progress note from 4.16.25. He stated that based on that note, and evidence a more thorough investigation should have been done. He stated he does check progress notes, but he has a lot of residents and can't go through all of them. He stated that the nursing staff should be the ones that brought this to his attention. Record review of facility Abuse/Neglect policy, undated, reflected the following: Each resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment, and involuntary seclusion. Mental abuse includes, but was not limited to, abuse that was facilitated or caused by nursing home staff taking or using photographs or recordings in any manner that would demean or humiliate a resident. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other resident, contractors, consultants or volunteers, staff or other agencies serving the resident, family members or legal guardians, friends, or other individuals.

Based on observations, interviews, and record reviews the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage. -The facility failed to keep a plastic bottle of barbeque sauce free of dried drippings around sides of the bottle. -The facility failed to keep spice bottles completely sealed. These failures could place residents at risk of food borne illnesses. Findings included: Observation on 02/04/2025 at 09:05, with the Dietary Manager during the initial tour in the kitchen, revealed the following:, The food preparation area by the food warmer revealed: -16 plastic bottles of spices stored on metal shelves directly above the food preparation area of which 5 spice bottles had opened tops. The refrigerator revealed the following: -A plastic bottle of barbecue sauce had dry dripping running down the side of the neck of the bottle. Interview with the Dietary Director on 02/06/25 at 12:56 PM revealed that staff were trained to close all containers after using each one. She stated that staff were trained to wipe containers and bottles after each use and reclose them to prevent dust and other particles from getting into the containers. She stated that bugs could get in unsealed bottles and containers causing contamination of spices and condiments. Regarding the open container of barbecue sauce, the Dietary Director stated, staff were trained to wipe containers before sealing them. She stated that she had reexplained the importance of cleaning them after use and keeping them clean. She stated having dirty bottles looked unsightly and can lead to contamination and that can lead to foodborne illnesses for the residents. Record Review of the facility''s policy and procedure on Cleaning the Refrigerators and Freezers Section: Sanitation -- revised 10/21/2024, reflected, Policy: Refrigerators and freezers will be maintained in a clean, sanitary condition and will be free from spills, food particles and odors to prevent cross contamination and food borne illness. Procedure: Refrigerator (daily): Check that all foods are properly covered, labeled, and dated. Straighten refrigerator inventory, placing older inventory to front of shelves. Wipe down all exterior surfaces with a solution of warm water and an all-purpose cleaner. Wipe dry with a clean cloth. Clean rubber wheels if applicable. Record review of the facility's policy and procedure on Food Safety in Receiving and Storage Section: Sanitation revised on 10/21/24, reflected in part, Policy: Food will be received and stored by methods to minimize contamination and bacterial growth. Procedure: Dry Storage Guidelines reads in part, Clean exterior surfaces of food containers such as cans or jars of visible soil before opening

Based on observations, interviews 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 the residents during lunch service observation. -The Director of Rehabilitation did not don gloves or properly disinfect resident's bodily fluids observed on the floor of the main dining room. This failure could place the residents at risk for communicable diseases or viruses. The findings included: In an observation on 02/04/25 at 12:28 PM, a resident was observed spitting on the floor and the facility's Director of Rehabilitation moved the resident to another table. He was then observed using a paper towel without gloves to wipe a resident's spit on the floor next to the dining room table with other residents present and eating their lunch. The Director of Rehab was observed cleaning the area with new paper towels and without gloves. He was observed using the same paper towel to pick up a dirty napkin from the same dining room table with the other residents present and eating their lunch. No disinfectant used during observation. During an interview with LVN K on 02/06/25 at 12:28 PM, she stated in instances for spills or liquids observed on the floor, the nursing staff was to put up a sign. LVN K stated housekeeping staff were notified so they could clean and disinfect spills. LVN stated the risks of not wearing gloves when cleaning bodily fluids included bacteria or viruses which could endanger other residents if the site was not cleaned properly. She stated the responsibility belonged to all staff. During an interview with ADON L on 02/06/25 at 01:22 PM, she stated protocol for bodily fluids observed on the floor would indicate for nursing staff to don gloves, clean fluids with disposable tissue, dispose tissue, and then clean with a disinfectant. ADON L stated if nursing staff were not able to properly clean and disinfect the area, they were to notify housekeeping staff for proper cleaning. ADON L stated that the risk of not donning gloves and disinfecting the area was transmission of communicable disease to the person cleaning and other residents around the area. In an interview with the Housekeeper on 02/06/25 at 02:42 PM, she stated for bodily fluids observed on the floor would indicate cleaning the area with gloves on and then disinfecting the area. She stated they were trained to wait for the kill time as indicated on the disinfectant, and then housekeeping staff would mop the area. She stated they use a new mophead to clean bodily fluids, which will be bagged and placed in the laundry room, so the mophead was not used for any other reason. She stated the risks included the spread of hepatitis b, or other viruses if the area was not disinfected. In an interview with the DON on 02/06/25 at 02:52 PM, she stated staff were to wear gloves and clean bodily fluids such as saliva, with paper towels and notify housekeeping staff since they have the required chemicals to disinfect the area. She stated the risk was an infection control issue as saliva or bodily fluids can spread infection, or communicable diseases or viruses. The DON stated all staff were to wear gloves when in contact with bodily fluids. In an interview with the Director of Rehabilitation on 02/06/25 at 03:55 PM, he stated the facility staff were to use gloves and disinfectant when in contact with bodily fluids. He stated this was to prevent skin contact from person to bodily fluid. He stated the responsibility belonged to all staff if a spill was observed. They were to clean and disinfect the area. The risks included transmission of illness to staff or other residents. The Director of Rehabilitation stated he was made aware of a resident spitting on the floor by a state surveyor and he then moved the resident to another dining room table. The Director of Rehabilitation stated he then cleaned the area without gloves. He stated he used paper towels because he did not think he could use cleaning solutions or disinfectants during the meal service. He stated the cleaning staff cleaneds and disinfecteds the dining room after each meal service. He stated that the risk of bodily fluids on the floor included falls, or transmission of illness. During an interview with the Administrator on 02/06/25 at 04:24 PM, he stated the proper protocol for cleaning of bodily fluids included hand hygiene, and donning PPE in order to prevent the spread of infection. He stated that typically housekeeping staff used chemicals to clean and disinfect areas exposed to bodily fluids. The Administrator stated using paper towels without gloves to clean bodily fluids could pose a risk for infection as the fluid couldan soak through the paper towel and contaminate the skin. The Administrator stated the cleaning chemicals and disinfectant were not to be used during meal service as it could contaminate the food being served. He stated all residents at the affected area should have been moved to another dining room table so housekeeping staff could clean and disinfect the bodily fluids properly to prevent infection or illness. Record Review of the facility's policy Infection Prevention and Control Program not dated, read in part: Employees -Supports resident safety by adhering to all policies and procedures related to infection prevention; Participates in performance improvement activities by promoting enhanced hand hygiene and adherence to respiratory hygiene/cough etiquette.

Based on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 2 (Resident #20, Resident #38) of 8 residents. Resident call lights were not kept within reach for Resident #20 and Resident #38 This failure places residents at risk of having needs unmet when they are unable to contact staff. Findings included: Resident #20 Record review of Resident #20's face sheet dated 02/04/25 revealed he was admitted on [DATE]. Record review of Resident #20's history and physical dated 01/26/24 revealed he was an [AGE] year-old male diagnosed with generalized muscle weakness, difficulty in walking, abnormalities with mobility and lack of coordination. Record review of Resident #20's MDS revealed he had a BIMS score of 3 indicating severe cognitive impairment. Review of Resident #20's Functional Abilities revealed he required moderate assistance with oral hygiene and upper body dressing as well as maximal assistance with toileting hygiene, shower, lower body dressing, putting on or taking off footwear and personal hygiene. Record review of Resident #20's care plan reviewed on 12/12/24 revealed Resident # 20 was at risk for falls due to new environment and/or age and stated the resident's call light needed to be within reach and for staff to encourage the resident to use it for assistance as needed. It stated the resident needed a prompt response to all requests for assistance. Resident #38 Record review of Resident #38's face sheet dated 02/04/25 revealed he was admitted on [DATE]. Record review of Resident #38's history and physical revealed he was a [AGE] year-old male diagnosed with cerebral palsy (a group of disorders that affect movement and muscle tone or posture), unspecified lack of coordination, generalized muscle weakness, paraplegia (a type of paralysis that affects the lower half of the body.) and quadriplegia (a type of paralysis that affects all four limbs, both arms, and both legs.). Record review of Resident #38's MDS revealed he had a BIMS score of 0 indicating severe cognitive impairment. Review of Resident #38's Functional Abilities revealed he required moderate assistance for feeding as well as maximal assistance with oral hygiene, toileting hygiene, shower, upper and lower body dressing, putting on or taking off footwear and personal hygiene. Record review of Resident #38's care plan reviewed on 12/11/24 revealed that the resident's call light needed to be within reach and for staff to encourage the resident to use it for assistance as needed. It stated the resident needed a prompt response to all requests for assistance. In an observation on 02/04/25 at 09:05 AM in Resident #20's room, the resident was asleep facing up. His call light was tangled and hanging from his bed rails to his left side about two inches from the floor. In an observation on 02/04/25 at 09:05 AM in Resident #38's room, the resident was lying in bed facing up. Resident# 38 was interviewed and said he used the call light when he needed assistance from the staff. Resident #38 said he would not be able to reach his call light since it was hanging behind his bed out of his reach. Resident # 38 said that when this happened, he would wait until a staff member went into the room to check on him or his roommate to then request for his call light to be placed near him again. Resident # 38 said that sometimes it would take a long time for staff to check on them but was not able to say an approximate period . In an interview on 02/05/25 at 03:00 PM LVN H, she stated call lights needed to be within residents' reach. LVN H explained not having a call light within reach could result in a resident being unable to call for help, and subsequently, not receiving the help they needed. LVN H stated that all staff are responsible for conducting rounds of the residents' rooms to ensure that the call lights are properly placed and within reach. In an interview on 02/05/25 at 03:14 PM with CNA I, she stated she had received training regarding call lights, their use, and placement. CNA I said call lights were supposed to be within reach of every resident so that the residents could request assistance if needed. She said not having a call light within reach could result in the resident not getting help if they needed assistance, or if there was an emergency, they possibly could not contact staff to promptly help them. In an interview on 02/06/25 at 09:36 AM with the DON, she said the call light needed to be within reach of a resident to assist them with their needs and to help them with medications or toileting or whatever they needed help with. The DON said a risk could be that a resident tried doing something on their own, which could result in falls, injuries or staying wet or soiled which could result in issues with their skin integrity. DON said staff was to check for call light placement every two hours and as needed. She said having rounds every two hours helped to detect any call lights that were not within reach. In an interview on 02/06/25 at 09:42 AM with the Administrator, he said the call light being within the reach of a resident is for them to be able to call for assistance when they need it. Not having the call light within reach would delay the resident receiving help. If a resident does not receive assistance in a timely manner the resident could be left soiled and without being changed or if there was an emergency, it could delay the time for them to get assistance. Record review of the facility's policies and procedures, not dated, titled Section C, Call Lights, stated in part: The call light must always be within resident's reach before you leave the room.

Based on observation, interview and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 1 of 6 residents (Resident #18) reviewed for ADL s. The facility failure to provide nail trimming for Resident #18. This failure placed the resident at risk for injury, infection and decreased quality of life. Findings include: Record review of the Face Sheet for Resident #18 revealed she was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE] with the following diagnoses: Muscular dystrophy (a group of genetic diseases that cause progressive weakness and loss of muscle mass), Type 2 Diabetes Mellitus. Record review of Resident #18's history and physical dated 12/03/24 revealed she is an [AGE] year-old female diagnosed with Muscular Dystrophy with progressive weakness, and Diabetes Mellitus type 2. Record review of Resident #18's care plan dated 02/06/25 revealed the resident is at risk for complications related to having Diabetes Mellitus and staff is to encourage Resident #18 to practice good general health practices including good hygiene. Review of the MDS Admission assessment for Resident #18 dated 11/29/24 reflected a BIMS (a cognitive screening tool used to assess a person's orientation and short-term memory with a scoring range of 0-15, where higher scores indicate better cognitive function) score of 10 indicating moderate cognitive impairment. Review of MDS revealed Resident #18 scored a 2 under Personal Hygiene, which indicate the resident is in need of Substantial/Maximal assistance and the helper is to do more than half the effort with assistance. During an observation on 02/04/25 at 02:48 PM, Resident #18 was observed with long nails. Resident #18 stated the facility's staff have not offered to trim her nails. Resident #18 was unable to recall last nail trimming service. Resident #18's right thumb's nail was observed approximately 1/2 inch long. Resident #18's left thumb nail was observed approximately 2 centimeters long. Resident #18's left middle finger, ring finger, and the smallest finger, was observed approximately 2 centimeters long. During an Interview with LVN K on 02/06/25 at 01:04PM, she stated the resident's nail care is provided on the weekends. She stated the CNAs are reminded to provide nail care or grooming for residents via text message. LVN K stated the CNA's are responsible for nail care, unless the resident is diabetic. She stated the nurses will provide nail care for diabetic residents. LVN K stated the nurses are responsible for overseeing the CNA's. She stated activities staff also provide nail painting for residents and if there are concerns, it is brought to the attention of the nurses. LVN K stated, It is also the resident's choice to refuse nail care, but nursing staff is to educate the residents and clean the nails. She stated that Resident #18 does not like to have her nails clipped and refuses but will let the nursing staff clean her nails. LVN K stated Resident #18 is diabetic, so the nurses are responsible for nail trimming. She stated the risks include infection, or resident could scratch self or others. In an interview with ADON L on 02/06/25 at 01:19PM, she stated staff is to ask the resident for permission before providing nail care. She stated if the resident is diabetic, nails are to be cut only by a nurse. ADON L stated nursing staff tries to provide nail care regularly. ADON L stated the risks for residents with long nails include scratching self, others including residents or staff, and infection. During an interview with Activity Director on 02/06/25 at 02:21 PM, she stated the activities staff paints residents' nails once a month. The Activity Director stated she will trim the residents' fingernails at that time if the resident is not diabetic. She stated if she has concerns about a resident's nail length, she will notify the nurse. She stated if there are requests for nail care on Saturdays, the Activity Assistant will provide the service. She stated Resident #18 is scheduled for 1-on-1 activities three times a week but refuses activities a lot. She stated the Activity Assistant usually does 1-on-1 with residents. During an interview with Activity Assistant on 02/06/25 at 02:27 PM, she stated she paints the residents' nails monthly, and during her 1-on-1 activities, if requested. She stated that she will get the nurse to cut the resident's nails if they are too long. Activity Assistant stated Resident #18 is scheduled for 1-on-1. Activity Assistant stated Resident #18 does not really want to do anything regarding her nails. She also stated Resident #18 was offered nail care approximately 1 month ago. The Activity Assistant stated the risks for the resident include bacteria can get underneath the nails. During an interview with DON on 02/06/25 at 02:55 PM, she stated CNA's trim or file down residents' nails once a week or as needed. She stateds Sundays are Nail Day, and CNA's offer nail care or other grooming to residents every Sunday. She stated the risk of residents having untrimmed nails included ripping of the nail, infection control as dirt can go underneath the nail. DON stated diabetic residents are at higher risk if nails are not cut or trimmed properly. Record Review of facility's policy Nail Care-Fingernails and Toenails with no date, read in part: Purpose 1. To promote cleanliness 2. To prevent injury 3. To prevent infection.

Based on observations, interviews, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (Hall 5 nurse cart) of 4 medication carts inspected for medication reconciliation. RN A did not document the administration of a controlled medication (Tramadol) on the individual controlled medication records after she had administered the medication on 02/04/2025. This failure could place residents at risk of under dose, overdose, and drug diversion. The findings were: During an observation on 02/04/25 at 10:46 AM the medication cart for hall 500 was inspected with RN A present. The controlled medication drawer was checked, and the medications were compared with their corresponding medication sheet. Two of the medication packets were found to be off by 1 number. The medication was Tramadol 50mg, the medication packet contained 20 pills, and the corresponding count sheet indicated 21 pills left in the packet. The second medication was Tramadol 50mg, and the packet contained 11 pills, and the corresponding count sheet indicated 12 pills left in the packet. During an interview on 02/04/25 at 10:54 AM RN A said that she usually signed the controlled medication sheets after she administered the medication and not after she poured the medication. RN A said as far as she knew this was okay to sign the medication afterwards or even at shift change. During an interview on 02/06/25 at 03:42 PM the ADON said it was expected for the nurses to sign out any controlled medications as soon as they administered them. The ADON said this was best practice and it was expected to be done to keep an accurate count of the controlled medications. The ADON said if for some reason the nurse had to leave immediately then this could lead to the count being off. The ADON said they had done training on signing out the controlled medications and they would do reminders for staff to sign out the medications. During an interview on 02/06/25 at 04:06 PM the DON said it was expected for the nurses to keep the control medication binder up to date such as the controlled medication count. The DON said there wasn't an exact expectation on when to document the count. The DON said it was best practice to document the controlled medication was administered, as soon as they administered the medication to keep an accurate count. During an interview on 02/06/25 at 04:07 PM the Administrator was made aware the controlled medication record was not correct when reconciled with the corresponding blister pack. The Administrator acknowledged it was an issue. Record review of the undated document titled Narcotic count indicated in part: The nurse (CMA) counting the pills will call out to the nurse (CMA) reading the narcotic count sheet how many pills are on hand. The nurse (CMA) reading the narcotic count sheet will confirm the number of pills, after the last recorded dose was given, matches the number of narcotics on hand. Any discrepancy will immediately be reported to the charge nurse and/or ADON, who will attempt to reconcile the discrepancy.

Based on observations, interview, and record review the facility failed to ensure that the resident has a right to a dignified existence and treat each resident with respect and dignity for 1 (Resident #45) of 8 residents reviewed. Resident #45's nephrostomy bag (a sterile disposable bag used to collect urine that is drained from the kidney through a tube) was not placed in a privacy bag. This failure could place residents at risk of diminished quality of life and compromise residents' dignity. Findings include: Record review of Residents # 45's face sheet dated 02/05/2025 revealed she was admitted on [DATE] and readmitted on [DATE]. Record review of Residents # 45's history and physical dated 07/24/2024 revealed a 75-years-old-female diagnosed with other mechanical complication of other urinary devices and implants, pain due to genitourinary prosthetic devices (medical implants designed to restore or improve the function of the urinary system), hydronephrosis (a condition that occurs when urine backs up into the kidney), acute kidney failure with tubular necrosis (a type of kidney injury that occurs when the cells lining the tubules of the kidneys are damaged or destroyed), obstructive and reflux uropathy (conditions that affect the urinary tract). Record review of Residents # 45's quarterly MDS dated [DATE] revealed she had a BIMS score of 9 indicating she was moderately cognitively impaired. Record review of Residents # 45's care plan reviewed on 11/01/2024 revealed she had an indwelling catheter and requested to ensure the foley privacy bag was in place. During an observation and interview on 02/04/25 at 09:45 AM, Resident # 45 was laying in bed to her left side. A nephrostomy bag was on top of the bed sheets beside the resident. The bag was placed inside a clear plastic bag and not inside a privacy bag. Urine was noticed inside the bag and in the tubing. Resident# 45 stated she liked the bag beside her because it was easier for her to reposition in bed and when transferring to her wheelchair. Resident #45 stated it was her preference to have it next to her so she could see the amount of urine in the bag and that way she could drain the urine or request assistance to drain it. Resident # 45 said that some times the nephrostomy bag slipped out of the privacy bag when it was placed inside the clear plastic bag, but that it did not bothered her because that's how she was able to see how much urine there was inside the bag and determine if she needed to drain it. In an interview on 02/05/25 at 03:00 PM LVN H said that the expectation was for the nephrostomy bags to always be inside a privacy bag. She said not having a nephrostomy bag inside the privacy bag could result in a resident feeling ashamed and there was a probability of making the resident feel like their right to privacy was being violated. LVN H stated that it was also to protect other residents who might not want to see Resident# 45's bodily fluids. LVN H said nephrostomy bags needed to always be inside a privacy bag. In an interview on 02/05/25 at 03:14 PM with CNA I she stated the nephrostomy bag needs to be inside the privacy bag so that no outsiders can see the urine and to provide privacy and dignity to the resident as well as to their roommate. CNA I stated that not having a nephrostomy bag inside of a privacy bag could result in making the resident feel ashamed or that their privacy was not being respected. CNA I said that there was also a risk if the bag was not in the privacy bag it could tear and have spills which could potentially be carried by other staff into other rooms and infect other residents if that resident had some kind of infection. In an interview on 02/06/25 at 09:22 AM with the DON, she said the nephrostomy bag or any bag with bodily fluids should be covered for privacy and for infection control purposes. The DON said the risk of having a bag exposed was possibly violating Resident #45's rights and her privacy. She stated the resident could have feelings of shame and psychosocial issues. DON said if the bag was altered in any other way there would be a possibility of having those fluids spill and contaminate other areas. In an interview on 02/06/25 at 09:42 AM with the Administrator, he stated that the purpose of a privacy bag is to promote dignity and privacy for the residents. He stated that if a bag with bodily fluids is exposed and not inside a privacy bag, it could result in dignity issues or violations of a resident's rights. Record Review of the undated facility's policy titled Catheter Care reflected it did not address the necessity of the foley bag being placed into a privacy bag. The Administrator and the DON stated on 02/06/25 at 11:00 AM the facility did not have a policy addressing privacy bags .

Based on observations, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #45) of 8 residents reviewed. Resident #45's urinary catheter nephrostomy bag bag was not placed below the bladder. This deficient practice could place the residents at risk of urinary tract infections. Findings include: Record review of Residents # 45's face sheet dated 02/05/2025 revealed she was admitted on [DATE] and readmitted on [DATE]. Record review of Resident # 45's history and physical dated 07/24/2024 revealed a 75-years-old-female diagnosed with other mechanical complication of other urinary devices and implants, pain due to genitourinary prosthetic devices (medical implants designed to restore or improve the function of the urinary system), hydronephrosis (a condition that occurs when urine backs up into the kidney), acute kidney failure with tubular necrosis (a type of kidney injury that occurs when the cells lining the tubules of the kidneys are damaged or destroyed), obstructive and reflux uropathy (conditions that affect the urinary tract). Record review of Resident # 45's quarterly MDS dated [DATE] revealed she had a BIMS of 9 indicating she was moderately cognitively impaired. Record review of Resident # 45's care plan reviewed on 11/01/2024 revealed she had an indwelling catheter related to acute pyelonephritis (a kidney infection that is usually caused by bacteria. It is a type or urinary tract infection that starts in the bladder and then spreads to the kidneys). During an observation and interview on 02/04/25 at 09:45 AM, Resident # 45 was laying in bed to her left side. A nephrostomy bag (a sterile disposable bag used to collect urine that is drained from the kidney through a tube) was on top of the bed sheets beside the resident. The bag was placed inside a clear plastic bag. Urine was noticed inside the bag and in the tubing. Resident #45 stated she liked the bag beside her because it was easier for her to reposition in bed and when transferring to her wheelchair. Resident #45 stated she had been educated of the risks for having the bag above the bladder but that it was her preference to have it next to her so she could see the amount of urine in the bag and that way she could drain the urine or request assistance to drain it. In an interview on 02/05/25 at 03:00 PM with LVN H, she stated that nephrostomy bags needed to be placed hanging from the bed frame below the resident's bladder or kidneys so that they could properly drain. LVN H stated the resident had been instructed on the risks of having the nephrostomy bag on her bed. LVN H said she did not remember if a care plan had been created regarding education being provided for Resident #45. She said risks discussed with the resident included the bag not draining properly and the risk of infection. LVN H mentioned Resident #45 sees a nephrologist and had been told they would remove the bags, but LVN H said she did not know when the bags would be removed. In an interview on 02/05/25 at 03:14 PM CNA I stated the nephrostomy bags are supposed to be hanging on the side of the bed below the waist. CNA I said that the purpose of the bag placed below the bladder or kidneys of a resident was for urine to drain properly. CNA I said the risk of not hanging a nephrostomy bag below a resident as it's supposed to be placed, was that the cord could get wrapped around the resident and tug the nephrostomy tube or bag, causing pain or discomfort to the resident or the bag could tear spilling its contents. CNA I said there could be a risk of a Urinary Tract Infection (an infection that affects parts of the kidneys or urethra). In an interview on 02/06/25 at 09:22 AM with the DON she stated the nephrostomy bag should always be positioned lower than the bladder so it can properly drain, and it does not backflow. The DON stated if it did not drain properly the Resident could be susceptible to infection and UTIs and other complications with infections. DON said if the urine back flowed, it would also pose a risk for UTI . The DON said Resident #45 liked to manage her nephrostomy bag and place it on her side. The DON stated that Resident #45 was aware the bag needed to be below the bladder. The DON said that Resident #45 had expressed to the facility that she knew what she was doing and that she knew how to take care of herself. The DON expressed Resident #45 could get upset when placement of the nephrostomy bag was discussed with her. The DON informed that Resident #45 had received education on placement of her nephrostomy bag. The DON said she believed a conversation should happen between the facility and Resident #45's nephrologist regarding the removal of the nephrostomy bags, but to her knowledge that had not been done. In an interview on 02/06/25 at 09:42 AM with the Administrator, he stated the nephrostomy bag should be placed below the resident's waist so that it can properly drain and to avoid infections and for the urine to backflow. He stated that the risk of placing the bag at the same level as Resident #45, could put her at risk of infection. The Administrator stated that some residents signed an informed consent form where they are informed about the risks of refusing treatment and said he would look to see if Resident #45 had signed one for having her bag at bladder level. In an interview on 02/06/25 at 11:00 AM with the DON and Administrator revealed the care plan for Resident #45 stated the facility would monitor the resident for nephrostomy bag placement but did not note encouragement or interventions to relocate the nephrostomy bag below the bladder or kidneys. The DON and Administrator stated Resident #45 did not have a signed informed consent form mentioning that Resident #45 had received education on the risks for not placing the nephrostomy bag below the kidney/bladder level and denoting her refusal for proper treatment. The DON and the Administrator confirmed that the facility lacked a policy addressing Foley catheter and nephrostomy bag placement on 02/06/2025 at 11:00 AM.

Based on observations, interviews, and record reviews the facility failed to ensure that a resident who neededs respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #29) of 17 residents observed for oxygen management. - The facility failed to ensure Resident #29's oxygen tank was not empty behind her wheelchair while she was in the dining area. These failures could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health. Findings included: Resident 29 Record review of Resident #29's face sheet dated 02/06/25, revealed an, admission on 08/09/23 and re-admission on 01/12/24 to the facility. Record review of Resident #29's medical diagnoses dated 02/06/25, revealed, an [AGE] year-old female diagnosed with history of pneumonia unspecified organism and , chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs). Record review of Resident #29's MDS dated [DATE], revealed BIMS score of 15. Indicating that the resident has intact cognition and is likely to fuction normally and may need the least amount of support from staff. Record review of Resident #29''s orders dated 01/11/25, revealed, OXYGEN -- CONTINUOUSLY = Oxygen at 3 Liters per min via nasal cannula continuously. Check every shift. Check oxygen saturation every shift and keep oxygen saturation at or greater than 92%. Record oxygen saturation every shift. Record review of Resident #29's care plan dated 01/15/25, revealed, the resident has oxygen therapy as needed to keep saturations above 92%. An observation on 02/04/25 at 12:30 PM revealed resident having lunch in dining area, oxygen tank behind her chair was on empty. The State Surveyor brought this to a Medication Aide F's attention, and she went to retrieve another tank, and she also let the residents assigned nurse (LVN G) know. Medication Aide F changed the tank, and nasal cannula. LVN G measured oxygen saturation using a pulse oximeter. The oxygen saturation was at 90%. In an interview with Medication Aide F on 02/06/25 at 01:12 PM revealed that the protocol that she was trained to follow was to get the nurse to change oxygen because it was a medication. She stated that it was the responsibility of anyone who noticed the oxygen tank to be running low or to be empty to report it to the nurse to change the tank. She stated that the risk of residents having an empty oxygen tank was the residents could run low on oxygen and it could lead to trouble breathing. In an interview with LVN G on 02/06/25 at 01:16 PM revealed that all residents with oxygen tanks and concentrators were rounded on every morning and mid- day before going out to lunch. She stated that Resident #29 was alert and oriented and she was usually the one who lets the staff know when her oxygen tank [NAME] running low. LVN G stated that she usually rounds on everyone in the morning and before lunch time. But, this resident was independent enough to wheel herself out of the room and into the dining area, that she wheeled her self to the dining area before she could verify that the tank was full . The risk of the resident running out of oxy gen was that it could lead to hypoxia. In an interview with the DON on 02/06/25 at 02:48 PM revealed that oxygen tank rounds should be done in the dining room by nursing staff including CNA's and nurses. She stated and there was no set time for nurses to round on the oxygen tanks. All direct care staff were were required to monitor residents every 2 hours. The risks to residents that were not being properly oxygenated are desaturating, and hypoxia. She stated that residents have their oxygen for a purpose. In an interview with facility administrator on 02/06/25 at 04:35 PM revealed that residents should be checked if taken to the dining room, that particular resident makes their needs known. The resident will let the nurse know that oxygen was running low. The risk of the resident running out of oxygen was that it could cause harm by ineffective breathing. Record Review of the facility's oxygen policy and procedure provided titled Administration of Oxygen and Administration of Cannula, not dated, revealed no specific policy on rounding and checking oxygen tanks.

Based on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment to prevent complications for 1 of 1 residents (Resident #83) reviewed who received their feeding through a percutaneous endoscopic gastrostomy (PEG) feeding tube. The facility failed to ensure CNA C and CNA E did not lower the head of the bed flat while the PEG (A PEG tube is a thin, flexible tube inserted through the abdominal wall and into the stomach. It is used to provide nutrition and medications to patients who cannot eat or drink normally) pump was still infusing the formula, during personal care performed for Resident #83. This failure could affect residents with PEG tubes and could result in unwanted outcomes such as aspiration pneumonia. The findings: Record review of Resident #83's admission record dated 02/06/25 indicated she was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and dementia. She was [AGE] years of age. Review of Resident #83's quarterly MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = severely impaired. Always incontinent of both bladder and bowel. Nutrition approach - feeding tube. Record review of Resident #83's Physicians Orders dated 02/06/2025 documented in part: Enteral Feed Order every shift G-TUBE- via g-tube and pump. Head of bed elevated 30-45 degrees at all times. During an observation on 02/04/25 at 12:21 PM CNA C and CNA E performed incontinent care for Resident #83. Both CNAs entered the room, washed their hands and then donned PPE. CNA C then lowered the head of the bed flat while the PEG pump was still flowing or infusing the formula. The CNAs performed all the incontinent care while the resident was flat and the pump was on the on position. There was no observation of the resident aspirating during the entire care process. During an interview on 02/04/25 at 03:32 PM CNA C said as far as she knew they never paused or touched the PEG pump when they performed incontinent care. The CNA said as far as she knew the nurses knew about them performing incontinent care and they had not paused the pump before. The CNA said she was not aware of an order indicating the HOB should be at 30-45 degrees up at all times. During an interview on 02/06/25 at 03:46 PM the ADON said it was expected for the CNAs to notify the nurse to pause the PEG pump before they performed incontinent care as they had to lay the head of the bed flat. The ADON was made aware of the observation of the incontinent care performed with the pump on the on position and the head of the resident's bed being flat. The ADON said if the CNAs left the pump on, and the resident's bed was totally flat then it could lead to aspiration pneumonia. The ADON said the failure occurred because the CNAs failed to notify the nurse to pause the pump. During an interview on 02/06/25 at 04:12 PM the DON said it was expected for the nurses to pause the PEG pump whenever the CNAs performed incontinent care on the residents. The DON said it was expected for the HOB to be elevated to at least 30 degrees when the PEG pump was on. The DON said if the HOB was lowered with the PEG pump that could lead to the resident aspirating. The DON said she believed the failure occurred because the CNAs failed to notify the nurse to pause the pump and that they would be conducting more training. During an interview on 02/06/25 at 04:09 PM the Administrator was made aware of the observation of the CNA lowering the HOB flat during incontinent care and the PEG pump being on. The Administrator acknowledged it was an issue. Record review of the undated document titled Tube medication administration indicated in part: Leave head of bed elevated as ordered with call light accessible. This prevents aspiration of stomach contents.

Based on observations, interviews, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 medication carts (Hall 500 Nurse Med Cart) reviewed for medication storage. The facility failed to ensure the Hall 500 Nurse Medication Cart contained an insulin pen with an open date. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings included: During an observation on 02/04/25 at 10:46 AM the medication cart for hall 500 was inspected with RN A present. On the top drawer were several insulin pens. One of the insulin pens had been opened but there was no open date observed on the pen. During an interview on 02/04/25 at 10:55 AM RN A said that she was not sure why the insulin pen did not have an open date on it. The RN said she usually dated it when she opened it, the RN disposed of the insulin pen. The RN said she had disposed of the pen because now they would not be able to tell when it would expire as they were only good for 28 days. During an interview on 02/06/25 at 03:44 PM the ADON said it was expected for the nurses to label and write an open date on the insulin pens when opened. The ADON said the pens had to be dated when opened so they could tell when it had been 28 days since most insulin pens would expire. The ADON said if the insulin pen was used after it had expired it could not be as effective. The ADON said it was expected for the nurses to know when to dispose of expired insulin pens and they conducted training on monitoring their (nurses) carts. During an interview on 02/06/25 at 04:08 PM the DON said it was expected for the nurses to document an open date on the insulin pen when opened. The DON said it was supposed to be dated so that the nurse would know when the medication was expired as they usually only lasted 28 days. The DON said the failure occurred because whoever opened the insulin pen failed to document when it was opened. The DON said they checked the carts at least once a week for expired medications but not necessarily done weekly. During an interview on 02/06/25 at 04:09 PM the Administrator was made aware of the insulin pen not having an open date when opened. The Administrator acknowledged it was an issue. Record review of the undated document titled Administration of insulin did not indicate anything regarding dating of insulin. This was the only policy/document provided by the facility. Review of the undated insulin pen container indicated Discard unused portion 28 days after first opening.

Based on observations, interviews, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 diet test trays reviewed for food temperatures. -The facility failed to maintain hot food on the served test trays. -This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: Interviews with residents during initial rounds on 02/04/25 revealed 6 out of 20 residents complained of food being cold when served in their rooms. An observation on 02/05/25 at 5:45 PM revealed sample trays transported in open rolling cart because they did not fit in the insulated cart. One tray for a resident was observed to be placed on top of the insulated cart, due to it not fitting in the cart. Trays for the hall and sample trays all exited the kitchen at 5:53 PM and were taken to hall 500, all trays served to residents. Sample trays then transported to the conference room. Sampling of the test trays on 02/05/25 at 6:05 PM in the conference room, with the Dietary Director revealed: The Regular Diet Tray: Cheese ravioli with meat sauce was 122.2 degrees Fahrenheit. Mixed vegetables were 143.9 degrees Fahrenheit and bread roll was 100 degrees Fahrenheit. The Mechanical Diet Tray: Ravioli with meat sauce was 90 degrees Fahrenheit, mixed veggies were 100 degrees Fahrenheit, and bread roll was 98 degrees Fahrenheit. The Pureed Diet Tray: Ravioli with meat sauce was 95 degrees Fahrenheit, mixed vegetables were 90 degrees Fahrenheit, and bread was 80 degrees Fahrenheit. An interview with Dietary Director on 02/06/25 at 12:56 PM revealed the test tray temperatures were below temperature. , food should be at a temperature of 135 degrees Fahrenheit. She stated that the service cart was used because it was an extra insulated cart, and it would help keep temperatures at an adequate number. The risk of cold food served to residents included food borne illnesses from improper temperature foods. She also stated that food will not be as palatable for residents because the warmth keeps the aroma and makes the food enticing . An interview with the Administrator on 02/06/25 at 04:30 PM revealed that he noticed that sample trays were not in the insulated tray cart. He stated that there was an extra insulated cart in the kitchen, and he did not know why the Dietary Director did not use that one. He stated that it is all of the kitchen staffs responsibility to ensure food is kept warm. The risks of residents being served cold food could be the residents getting sick due to food borne illnesses and the food was not as palatable when it was cold . Review of grievances on 02/06/2025 at 09:00 AM revealed no grievances filed regarding kitchen food temperatures. Review of the facility's policy and procedure on Safe Food Temperatures dated 11/15/24 revealed in part, Food temperatures will be maintained at acceptable levels during food storage, preparation, holding, service, delivery, cooling, and reheating. The time that food is in the temperature danger zone (41 to 135 ) throughout the food handling process is minimized to no more than 4 hours. Food is cooked to at least 135 F or to its minimum safe internal cooking temperature (whichever is higher). Foods can be cooked to higher temps if the quality is not sacrificed. All previously cooked food is reheated to an internal temperature of at least 165 F for at least 15 seconds. This temperature is achieved within 2 hours of cooking. Foods are reheated only once. Hot foods are held at 135 F or higher during meal service (on the trayline).

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 3 of 6 residents (Residents #1, #2, and #3) observed for resident rights. The facility failed to ensure staff assisting Residents #1, #2, and #3 did not stand while feeding them. This failure could place residents at risk for decreased meal satisfaction. The findings included: Review of Resident #1's Admission Record dated 5/30/24 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including strokes, paralysis on one side, and brain cancer. Review of Resident #1's quarterly MDS assessment, dated 5/1/24, revealedshe scored a 0 of 15 on her mental status exam (indicating severe cognitive impairment). She needed substantial to maximum assistance for eating. Review of Resident #1's care plan, last revised on 1/12/24 revealed Focus: Resident required extensive assist with late loss ADLS and feeding assistance with meals/mechanical lift transfer. The identified goal was Resident was able to perform self-care to optimal level and maintain strength and endurance for 90 days. None of the interventions addressed eating. Review of Resident #2's Admission Record, dated 5/30/24, revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, dementia, and Alzheimer's disease. Review of Resident #2's Significant Change MDS dated [DATE], revealed: She scored a 0 of 15 on her mental status exam (indicating severe cognitive impairment). She had physical and verbal behaviors that disrupted the resident's care and environment 1 - 3 days in the previous week. She needed substantial to maximum assistance while eating. Review of Resident #2's Care Plan, updated 5/30/24, revealed: Focus: Resident requires extensive assistance with late loss ADLs and the use of wheelchair for locomotion. The identified goal was Resident was able to perform self-care to optimal level and maintains strength and endurance for 90 days. Interventions included encourage independence in performance in self-care and mobility within limitations. Review of Resident #3's Admission Record, dated 5/30/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including stroke, dementia, and dysphagia (difficulty swallowing) Review of Resident #3's Significant Change MDS, dated [DATE], revealed: He scored a 0 of 15 on his mental status exam (indicating severe cognitive impairment). He needed supervision for eating. Review of Resident #3's care plan, dated 1/4/24 revealed a focus of Resident requires assist with ADLs. The identified goal was Resident was able to perform self-care to optimal level and maintain strength and endurance for 90 days. Interventions included encourage independence in performance of self-care and mobility within limitations. Review of Resident #3's care plan, updated 2/23/24 revealed, No added salt diet, regular texture, regular consistency. The goal was resident will maintain adequate nutritional status as evidenced by maintain weight through review date. Interventions included: 4/16/24 Resident no longer needs feeding assistance. Observation on 5/29/24 at 12:27 p.m., revealed CNA A stood while feeding Resident #1. CNA B stood while feeding Resident #2 and CNA C stood while feeding Resident #3. The lead CNA observed the three standing and brought two of them chairs, while CNA B reached behind her to another table to get a spare chair. While feeding Resident #1, CNA A had difficulty remaining seated because she kept kneeling up in the chair and then looking at the lead CNA or a nurse and sitting again. Interview on 5/29/24 at 12:41 p.m., the lead CNA stated CNAs needed to sit down while feeding because it was a dignity thing. The lead CNA stated the three aides forgot to get chairs and when he got them chairs, they remembered they needed to do that. The lead CNA stated the aides were monitored daily but he was responsible for monitoring the aides every Thursday. He said it had been a while since he had issues with the aides standing in the dining room while feeding. Observation on 5/30/24 at 12:43 p.m., staff were observed standing while feeding Resident #2. Interview on 5/30/23 at 1:24 p.m., the DON stated her expectation for the meal served was that the staff be seated while feeding the residents. She said it was inappropriate for the staff to be standing because the staff were supposed to be at eye level of the resident and be able to talk to the resident about what the resident was eating to see if the resident liked something or not within the resident's therapeutic diet. The DON said there was a meal monitor in the dining room and a nurse who were responsible to monitor for that. The DON stated normally the aides' put chairs where the dependent residents were fed prior to the meal service but the dining room was currently being remodeled so it was crowded so the staff were just trying to get residents into the dining room in where they could to feed them. The DON said she did see staff sitting to feed residents. Surveyor requested a policy for feeding residents. Interview on 5/30/24 at 1:58 p.m., the Administrator was informed of the staff standing while feeding observations. The Administrator stated he did not feel this was an issue due to the chaos going on related to the remodel in the dining room. He stated there were not chairs available. Surveyor pointed out the lead CNA was able to bring 2 chairs immediately to the table and the third CNA was able to go to the table immediately behind her for a chair. Surveyor also pointed out chairs could have been set up at the assisted table while the dining room was half-empty rather than waiting until the dining room was full. The Administrator said sitting while feeding was not outline specifically in the facility's policy. Follow up interview on 5/30/24 at 3:38 p.m., the Administrator said he did some investigation and the staff only reported that they only stood while cutting up the resident's meals during set up. Review of in-services provided by the facility revealed the staff were in-serviced: 4/19/24 Resident Rights on 4/19/24 that residents had the right to be treated with dignity, courtesy, consideration, and respect. (CNA A did attend this in-service) 5/6/24: Ombudsman's Resident's rights: Resident rights include being treated with respect, dignity and consideration. Review of the facility's undated policy and procedure on Feeding Residents in the Dining Room revealed: Purpose: To be sure all residents in the dining room have the assistance needed to complete their meal. Procedure: Staff member should position themselves so that the resident is at eye level with the staff member for better communication with the resident and to provide feeding in a dignified manner.

Based on interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent elopements for 1 (Resident #1) of 7 residents reviewed for accidents and supervision. The facility failed to provide adequate supervision to Resident #1. As a result, Resident #1 eloped from the facility at night along a highway and was located approximately 2 hours later in 44 Fahrenheit weather after he had fallen into a wet drainage ditch. Resident #1 was admitted to the hospital with diagnoses including hypothermia. An Immediate Jeopardy was identified on 01/04/24 at 3:02 PM. While the IJ was removed on 01/05/24 at 6:28 PM, the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed all residents that are an elopement risk at risk for serious injury, harm, and/or death. Findings included: Review of Resident #1's Admission Record, dated 1/2/24, revealed he was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including dementia, urinary tract infection, difficulty walking, diabetes, and history of falling. Review of Resident #1's Significant Change MDS Assessment, dated 11/22/23, revealed: -He had mental status exam of 2 of 15 (indicating severe cognitive impairment) with no signs of delirium. -He used a wheelchair, and the walker was not indicated. -He had a catheter. -He received IV medications and antibiotics. There were no falls in the look back time frame. Review of Resident #1's Care Plans revealed the following: -2/24/23: The resident has impaired cognitive function or impaired thought processes related to having dementia. A Goal was the resident will maintain current level of cognitive function through the review date. Interventions included: Administer medications as ordered. Monitor/document for side effects and effectiveness. Communicate with the resident/family/caregivers regarding resident's capabilities and needs. Discuss concerns about confusion, disease process, nursing home placement with resident/family/ caregiver(s). Engage the resident in simple, structured activities that avoid overly demanding tasks. -7/19/23 The resident is at high risk for falls due to new environment and cognitive deficits. Goal the resident will be free of falls through the review date. Interventions included: Educate the resident/family/ caregivers about safety reminders and what to do if a fall occurs. -2/24/23 The resident has a psychosocial well-being problem relate to mood indicators. Goal: The resident will identify ways of increasing meaningful relationships by the review date. Interventions included: Encourage participation from resident who depends on others to make own decisions. Increase communication between residents/family/ caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options. -Dated 1/2/24 (after entrance and after elopement) resident is at high risk for elopement related to poor cognition and previous incident. Goal: the resident will not leave facility unattended through the review date. Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Resident prefers: (blank). Identify pattern of wandering: Is wandering purposeful, aimless or escapist? Is resident looking for something? Does it indicate the need for more exercise? Intervene as appropriate. Monitor location every (Specify 15/30/60) minutes (Specify frequency) Document wandering behavior and attempted diversional activities in behavior log. Review of Resident #1's Brief Interview for Mental Status dated 10/26/23 revealed he had mental status score of 7 of 15 (indicating severe cognitive impairment). Review of Resident #1's Behavior Note, dated 12/26/23 at 9:29 p.m. revealed Resident #1 noted to be walking down different hallways, stopping different staff members asking in regard to a car accident, and a newspaper. Resident #1 then proceeded to be looking for his apartment on Hall 400. Nurse provided redirection, multiple times, only for patient to leave his room and continue to ambulate without assistance, or walker. Nurse aide redirected patient back to his room, patient proceeded to go and open his roommate's drawers. Redirection provided, and assisted patient into bed. Review of Resident #1'sTransfer out note, dated 12/31/23, at 10:30 p.m. revealed: Vital signs: unable to obtain: Clinical condition: elopement. Who transferred: city EMS. Time resident left facility: 10:10 p.m. Review of Resident #1's Incident Note, dated 1/1/24 at 2:22 a.m. revealed: This nurse noted resident in bistro at approximately 6:30 p.m. This nurse notified lead CNA to give resident his walker as he was walking without it. Resident then began to walk down hallway to room per lead CNA. At approximately 8:00 p.m. this nurse entered resident's room to check his blood glucose and noted resident was not sitting in his chair, his bed, or in the restroom. The nurse went down to bistro and was unable to locate the resident. The nurse was still unable to locate him. This nurse then searched every room and restroom on hall 500. The aide for the hall and MA were questioned, per MA she last saw him when his family member came to visit. At this time around 9 p.m. The nurse alerted staff on skilled unit to search all rooms on skilled unit. The exit doors on units were confirmed to be locked and the alarms were active. This nurse then spoke to the responsible party and confirmed resident was not with them. A full search of the building and perimeter of building with all staff commenced and the DON and Administrator were notified. Resident was noted at approximately 9:30 p.m. on ground next door at storage facility. Actions taken: 911 was called and EMS arrived and transported resident to ER. Physician notified: yes. DON notified: yes. Review of Resident #1's incident/accident reports (7/20/23 through 12/30/23) revealed no falls since 7/20/23. Review of Resident #1's Nursing Admission/ Readmission Assessment, dated 2/17/23 revealed an elopement risk assessment was completed at that time and he was assessed as not at risk for elopement at that time. Review of Resident #1's Emergency Department Triage Note dated 12/31/23 at 10:17 p.m. revealed: Resident #1 was confused and had a decreased cardiac output. He had altered mental status and was found outside laying on his side in the cold weather, patient was last seen at 6 p.m. His internal temperature was 92.5 degrees F. He was admitted to the local hospital with admitting diagnoses of heart failure, metabolic encephalopathy (condition where brain function is temporarily or permanently disturbed due to different diseases or toxins in the body), UTI, and hypothermia due to exposure. Review of the facility's Provider Investigation Report, completed 1/5/24 revealed, Description of the incident: Resident missing and was found on sidewalk next door by storage center (neighboring building to facility.) Resident was on ground. Found by staff, no injuries notes, resident was able to answer staff questions. Resident was seen by staff members a couple hours prior to being deemed missing and found. Actions and Notifications: 911 called, Administrator, DON, Family, and MDS all notified. In-service for elopement ongoing. This is resident's first occurrence of any type of elopement/wandering, will be assessed for elopement/ wander guard program in facility as he is a candidate for this intervention. Was the resident sent to the hospital: Yes What immediate actions has facility taken to protect the resident's health and safety as a result of the allegation? No injuries noted upon finding resident, staff able to stand resident and resident responsive/answering questions. Resident has been sent to hospital for further evaluation for any potential injuries/findings. Elopement in-servicer on-going and resident to be assessed for elopement / wanderguard program at facility as he a candidate for this intervention. Were the police notified? Yes. Were the physician, guardian and/or family notified? Yes. Was in-service training provided to staff as a result of this incident? Yes. Please provide the topic(s) of the in-services training(s): Elopement. Interview on 1/2/24 at 3:33 p.m. LVN A stated she was functioning as Resident #1's charge nurse the evening of 12/31/23. LVN A stated at the beginning of the shift around 6 or 6:30 p.m. she got report and saw Resident #1 walking down the hall walking without his walker. LVN A said she instructed a CNA to give Resident #1 his walker and continued to get report. LVN A stated she did her rounds and checked blood sugars. LVN A stated when she got to Resident #1's room she noticed he was not in there and she checked the bathroom and the 'bistro' area. LVN A stated she figured Resident #1 was walking and finished her rounds. LVN A stated she returned to Resident #1's room and did not find him. LVN A said she asked the nurse aide if she had seen Resident #1 and the nurse aide told her no. LVN A said after that she alerted the 600 hall charge nurse to check her hall and they searched public areas, rooms and bathrooms of the 400, 500 and 600 halls and still did not find Resident #1. LVN A said she was told Resident #1's family was there earlier in the day and they may have forgotten to sign him out. LVN A stated she called Resident #1's family to see if they did not have Resident #1. LVN A said after the family said they did not have Resident #1, LVN A called the other Nurse's Station to do a full facility sweep of the rooms, bathrooms, and public areas while she walked around the building and she did not see Resident #1. LVN A stated an aide looked further away from the building and that aide (CNA C) found Resident #1. LVN A said Resident #1 was found right next door by the road in between the building and the fence. LVN A described Resident #1 as laying in a fetal position on his left side and would not open his eyes. LVN stated Resident #1 was cold and pale, not shivering, and was not blue or red colored. LVN A state Resident #1 did not appear to have any injuries but did have a little abrasion over his lip. LVN A stated Resident #1 was able to answer simple questions. LVN A said Resident #1 reported he was ok and not in pain. LVN A stated she left Resident #1 in position she found him and called 911. LVN A said one of Resident #1's family members was present at the scene and she guessed the responsible party called them. LVN A said she did not have a lot of history with Resident #1. LVN A said did not have knowledge of him having a previous history of wandering. LVN A stated she covered Resident #1's hall at least weekly. LVN A stated in hindsight she would have been more diligent about making sure her residents were accounted for and getting with her nurse aides. LVN A stated as a team they were going to have to figure out a better plan to monitor the front door, but she did not know what. Interview on 1/3/24 at 12:15 p.m. LVN A stated Resident #1 was found wearing regular clothing pajama pants, she did not remember if Resident #1 was in a long sleeve shirt or a t-shirt. LVN A stated the staff were covering him up with jackets and blankets as soon as they found him. Review of CNA C's written statement (undated) revealed: I was informed that a resident went missing around 9 p.m. We went to all the rooms and all the bathrooms around the facility. Finally, I decided to go around and look outside. I walked toward the loop (highway) and when I turned to the left, I noticed a walker flipped upside down and when I walked toward it I found the resident in a fetal position. I asked him if he was ok and was he hurt and he said no. I took off my jacket and covered him. Interview on 1/3/24 at 4:05 p.m. CNA C stated she was on duty the night of 12/31/23. CNA C said she was alerted that Resident #1 was missing around 9 p.m. and checked the resident rooms on the side of the facility she worked. CNA C said then she checked outside. CNA C stated she asked if the family member took Resident #1 out and forgot to sign him out, but the family member said they had not. CNA C disclosed she worked at the facility a long time and most of the elopements had been towards the service road so that was where she went to check first. CNA C said when she looked, she saw what looked like wheels so she went to investigate. CNA C stated she found Resident #1 in a fetal position in a ditch and he was wet. CNA C stated Resident #1 could talk and said he was ok. CNA C said she took off her jacket and put it over Resident #1. CNA C stated she called the lead CNA and told him to get some blankets. CNA C said the nurses were the ones who called 911, but she did not know which one. CNA C said Resident #1 was so cold he could barely move. CNA C stated Resident #1 was wearing a black long-sleeved shirt, pants, and tennis shoes on. CNA C said she thought Resident #1's walker got stuck in the mud and then he rolled down the hill of the ditch because his back and side were wet and everything else was dry. CNA C repeated Resident #1 did not say he was hurt but she did notice a cut above his lip, but that was it. CNA C stated there was no way the staff could get Resident #1 up and out of the ditch and the best thing they could do was call 911. CNA C stated she heard the staff tell each other the last time they saw Resident #1 was after dinner was around 6:30 p.m. which was a bit steep. CNA C said no one said they gave Resident #1 his medication. CNA C said the charge nurse went to check his blood sugar and could not find him. CNA C said the nurse should have known then and no one saw Resident #1 for three hours. CNA C added we deserve this one, this one is bad. Review of Resident #1's Electronic Medication Administration Record revealed his medications for the evening of 12/31/23 were signed out at 8:36 p.m. Interview on 1/3/24 at 2:51 p.m. the DON stated MA D gave medication at approximately 7:30 p.m. in the bistro area so Resident #1 was out for less than two hours. The DON said Resident #1 did not have a history of exit seeking but had an increase of confusion. Review of MA D's written statement (undated) revealed: at about 6:15 p.m. or 6:30 p.m. I saw the family member walk by the nurse station and go down the hall. At around 7:45 p.m. I was standing at the cart preparing Resident #1's medications. I went to his room he wasn't in his room. I did check the restroom he wasn't there so I decided to check the bistro and he in fact was sitting in bistro. I gave him his medications and told him bye and walked back to hall 500 cart. A telephone interview was attempted with MA D on 1/4/24 at 9:39 a.m. but was unable to leave a message. Review of CNA E's written statement (undated) revealed: Saw resident headed down hall about 6:30 p.m. I stopped him and grabbed his walker from bistro. He continued down hall five. At 9 p.m. I was informed he was missing. We did a sweep inside the building checked bathrooms, beds, community showers. Then headed to parking log. Got a call from CNA A at 9:37 p.m. that she found him and to bring blankets. During an interview on 1/2/24 at 10:26 a.m. the Administrator and DON stated the facility had an elopement over the weekend (12/31/23). The DON stated the resident was in the hospital at the time of the interview. The DON said the resident was exit seeking the day of the elopement and that was not normal for him. The DON stated Resident #1 was admitted to the hospital for a Urinary Tract Infection and Hypothermia. The DON stated the LVN A last saw Resident #1 at 6:30 p.m. in the evening and at 8 p.m. the nurse was unable to find Resident #1 when the nurse went to do Resident #1's blood sugar. The DON explained the nurse completed evening rounds and then looked for him. The DON stated the nurse started checking the building and then the perimeter of the building. The Administrator added the facility's receptionist at the front door left at 5:30 p.m. that day. The DON said Resident #1 used a walker and he did not ambulate quickly. Observation on 1/2/24 at 10:59 a.m. revealed if Resident #1 left from Resident #1's room from the most direct route: Resident #1's room was the second to last room on his hallway and it was 205 small steps with three (3) significant bumps (bumps that a bed side table got stuck on) between the nurse's station and the front door. Interview on 1/2/24 at 12:57 p.m. CNA B stated she usually worked Resident #1's hallway and was familiar with him. CNA B said Resident #1 liked to be in his room but had become more confused. CNA B said Resident #1 used a walker and moved very slowly. CNA B said Resident # 1 tried to leave by the end of the hall door one time, but the aides were able to redirect him. CNA B said the aides were the ones to redirect him because they were closer; she said this happened once on her shift. CNA B said she did not know if the nurses knew. CNA B stated she was surprised Resident #1 went out the front door. Interview on 1/2/24 at 1:06 p.m. CNA C stated Resident #1 was able to move around the facility. CNA C stated Resident #1 was not always aware of his surroundings but was always pretty pleasant but paced back and forth in the facility some. Interview on 1/2/24 at 2:36 p.m. the Administrator stated he was not aware if the facility had a formal elopement assessment or not and he left the interview saying he would be right back. When the administrator returned at 2:46 p.m. the Administrator stated there was an elopement risk assessment on the admission/re-admission assessment. The Administrator said Resident #1 had an Elopement assessment completed 2/17/23 with no exit seeking behaviors noted and that was the last elopement assessment completed. Interview on 1/2/24 at 3:18 p.m. the Regional Consultant stated her understanding of the elopement was the nurse went to check Resident#1's blood sugar and could not find him. The Regional Consultant said the charge nurse checked for him in the bistro the rooms, did a head count, and checked the perimeter. The Regional Consultant stated she was unsure about the timeframes. The Regional Consultant stated the report she got was Resident #1 was found in the ditch. Interview on 1/3/24 at 11:43 a.m. Resident #1's Nurse Practitioner stated he was made aware of Resident #1's elopement. The NP stated the facility reported Resident #1 was found at the storage facility next door. The NP stated there was no time frame given for how long he was out. The NP said he was just told there was no obvious injuries. The NP stated Resident#1 always had a level of confusion due to a history of UTI's so there was no way to assess his cognitive states. The NP stated the residents at the facility were free to move around the facility and could come and go unless they had a band (wanderguard). The NP said hypothermia was variable and would depend on how cold it was outside and for how long the resident was outside but could cause major damage. The NP stated the beginning stage of hypothermia began with a body temperature of 95 degrees F. The NP stated he did not know what Resident #1's body temperature was when he was picked up. Interview on 1/3/24 at 1:21 p.m. Resident #1's Responsible Party stated Resident #1 was still in the hospital but was slowly stabilizing. The RP confirmed they did visit Resident #1 after church and [NAME] Resident #1 lunch and left around 3 p.m. the RP stated the facility called them at 9:30 p.m. to report the facility did not know where Resident #1 was and could not find Resident #1. The RP stated they sent another family member to look around the neighborhood. The RP stated she called the local police department at 9:39 p.m. (from her call logs on the cell phone). The RP said the family member texted them at 9:42 p.m. to say the family member was with the resident. The RP stated they were told by the family member Resident #1 was scratched up. The RP said Resident #1 told the RP Resident #1 left the facility to go home. The RP stated one staff member they did not identify told the RP that Resident #1 was last seen at 6 p.m. The RP stated concerns about the number of times staff did rounds or that no one went into Resident #1's room to check on him. Interview on 1/3/24 at 3:21 p.m. the Administrator stated the investigation into Resident #1's elopement he gathered Resident #1 got out of the facility around 7:45 p.m. and was found at 9:30 p.m. The Administrator stated he figured Resident #1 was out for an hour based on how slowly he moved. The DON who was present stated the consequences of hypothermia included the potential for death and hospitalization . The DON said as long as the body temperature could be brought back up there should not be lasting consequences. The DON said she did not know who called the police department that the resident was missing, but believed it was part of the policy and part of calling 911. m Interview and observation on 1/3/24 at 4:25 p.m. the DON and surveyor walked out the front door, across the 10 foot by 10 foot area of rock, the alley and to the ditch where Resident #1 was found. The DON said she did not know how Resident #1 got over the rocks without falling or how he fell down the ditch and only got minor injuries. Observation on 1/2/24 at 10:15 a.m. revealed the facility was built along one of the area's major highways, a divided 4 lane highway with 2 lane access road. The speed limit on the access road was 55 miles per hour. The landscaping immediately in front of the facility decorative rocks. Review of https://www.wunderground.com/history/daily/us/tx/midland/KMAF/date/2023-12-31 revealed the temperature on 12/31/23 at 8:53 p.m. was 47 degrees F. The temperature on 12/31/23 at 9:53 p.m. was 44 degrees F. Review of the facility's undated policy and procedure on Wandering/Missing Residents .To meet this need the facility will obtain information during pre-admission or admission conferences with the resident and family regarding any history of wandering or the potential for wandering. All instances of wandering or attempted elopement will be recorded in the medical record. A plan of care will be developed and implement with specific approaches and goals for the wanderer. The resident's name, picture, and physical description are placed in the wander book located at the nurses' station. When a resident is believed to be missing, the facility will implement the following steps: The charge nurse will be alerted the resident is missing. The charge nurse will alert all staff by announcing CODE GREY over the public announcement system and have staff report to the nurse station. Circumstances will be explained to the staff and each staff will be directed as to where to search. The entire building and grounds will be searched, including all shower rooms, closets, bathrooms, and entryways. If this search is unsuccessful, surrounding streets and yards will be checked. This search should not take longer than 15 minutes. IF the resident is not found withing 15 minutes, the administrator, director of nurses, HHS and the local police will be notified. HHS procedure will be followed regarding a missing resident. A current photograph and complete description will be given to the police of the missing resident. The charge nurse, director of nursing, or administrator will notify the family of the situation, what is being done and encourage their assistance. When the resident is located, the charge nurse will notify all previously contacted persons. Upon return to the facility, the resident will be assessed for injuries and the attending physician will be advised of the situation. A thorough incident report will be filled out by the charge nurse and given to the administrator. This will be documented in the resident's medical record. The charge nurse will be responsible for documenting the incident of residents leaving the facility. All documentation will be concise and reflect the actual facts as they relate to the incident, condition of the resident upon return to the facility, doctor's orders, treatment initiated, and any other information deemed pertinent by the facility. The time the police arrived and took over the search will be documented. The administrator will be responsible for preparing and investigation file of the incident, which is not a portion of the medical record. It is the responsibility of the facility administrator to ensure that the staff is fully aware of this policy. Review of the in-service on Emergency Exits, dated 12/19/23 revealed: door code is locked in emergency binder at each nurse's station. In the event that there is an alarm related to an emergency exit door ajar these are the steps to be followed: 1. See white box located at each nurse's station to verify which door is alarming. 2. Immediately report to the appropriate door. 2. Physically walk outside the door check to see if any residents are outside, if all clear step back inside and lock door. During an interview on 1/4/24 at 3:10 PM the Administrator, DON, and Corporate Consultant RN were informed that an Immediate Jeopardy Situation had been identified in the area of Quality of Care and the Immediate Jeopardy Template was emailed to the Administrator. Review of the in-service on Elopement, dated 1/1/24, revealed: Residents are to be checked every two hours to ensure safety. If a resident cannot be found in regular areas a building search is to be conducted of all patient rooms, bathrooms, common areas, parking lot, etc. Elopement binders are at both nurse's desks and front door, code grey is code for elopement. Review of the in-service on Secured Doors, dated 1/2/24, revealed: secured doors should be checked at the start of shift by nurses the code for side doors can be found in the fire book. The front door should be locked at 10 p.m. Review of the facility's Elopement Intervention, provided 1/3/24 at 4:19 p.m. revealed: Current population - elopement/ wander-guard program on all current residents/ admission/ re-admission for cognition changes (BIMS score, any indication of mental changes) Change of Condition - evaluate for elopement wander-guard program, if deemed appropriate, care plan meeting with RP / family, resident to be added to facility elopement binders. * The following Plan of Removal was accepted on 01/05/2024 at and included: The facility failed to ensure the residents are Free of Accidents Hazards/Supervisions/Devices. 1. All residents have the potential to be affected. Facility census on 01/05/2024 was 128. 2. MDS, ADON's and DON will assess all currents residents for changes in condition that would cause the resident to be considered a risk for elopement. All future admissions will be evaluated for elopement risk and be placed on a list at both the nurse's station and reception area. 3. Residents identified during assessment today (and in the future) found to be elopement risks and not suitable for care at will be supervised one on one until a more secure facility can be found to place the resident for their safety, such as a locked, secure unit. 4. The facility front door will be locked at 6 PM when the receptionist leaves for the day to ensure that no resident can leave or attempt to leave the facility without staff knowing and interceding. 5. DON and Lead-Aide will in-serviced and train all direct staff on the facility's elopement policy and procedure. 6. DON will in service all staff on communication priorities when any observation or issues present themselves whereas a resident has shown behaviors of wandering, either through a change in condition or increase in activity of wandering or made verbal requests to the staff concerning wanting to leave the facility. 7. All staff on leave will be educated prior to starting first shift back and completion of attestation form. 8. DON is responsible after a resident has been identified as an elopement risk to ensure that a proper assessment or care plan decision has been made and protective measures have been put in place until identified. 9. Any negative outcomes will be reported to the QAPI committee. The Medical Director was notified about the immediate jeopardy on 01-04-2024. Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interviews, and record reviews from 01/04/2024 at 3:02 pm to 01/05/2024 at 6:28 pm. Review of the facility's in service, dated 01/04/2024 presented by DON, covering Communication and Change of Condition indicated: *With and change of condition that occurs with any resident including physical, mental changes, any wandering or changes in behaviors a change of condition note needs to be initiated, DON and Administrator informed. *CNA's on floor with any changes identified with their residents will make sure to notify charge nurse. *All staff will notify DON and Administrator if any resident makes verbal requests to staff concerning wanting to leave the facility. Record review of a Facility Audit of the resident's medical records, performed by the DON, dated 01/04/2024, revealed that all residents were assessed for risk of elopement with 4 additional residents identified with wander guard orders initiated. During an interview, on 01/05/2024 at 12:10 PM, the Administrator stated if the facility identified an at risk resident for possible elopement the facility would place that resident on one-to one-supervision, the facility would call an emergency care plan meeting with the resident and/or the resident's family, the ombudsman, and the IDT. He said the facility would discuss the reasons for possible discharge and the facility would ensure the resident was discharged safely and appropriately, per regulations. The Administrator stated that the appropriate notices would be issued, and all other options would be explored before the discharge was done. Record review on 01/05/2024 at 12:45 PM revealed revised Orientation/Onboarding Power Point presentation containing slide with Elopement In-Service and attestation forms from presentation performed by administrator and DON. Review of sign in sheet of attendance revealed that 93 of 173 staff had completed on 01/04/2024 with Administrator stating that the facility was still in process of calling all staff to complete in-service. During an interview on 01/05/2024 at 2:26 PM CNA F (6PM to 6AM shift) stated that she received in-service training on 01/04/2024 for Orientation/Onboarding/Elopement. She stated she was aware that the front doors would be locked at 6:00 PM every night with entrance code posted on the outside of the door for visitors and visitors were to obtain the code to leave facility from staff. CNA F stated that she was in-serviced to report any changes to a resident's behaviors immediately to the charge nurse, DON, or Administrator. During an interview on 01/05/2024 at 2:32 PM Corporate Consultant RN stated that an assessment of all residents was performed on 01/04/2024 for all resident to identify elopement at risk. Stated that there were 5 new residents identified with physician notified to obtain wander guard orders. Corporate Consultant RN stated that there were no resident's identified as unsuitable for care at the facility during assessments. During an interview on 01/05/2024 at 2:40 PM MA G (2PM to 10PM shift) stated that she attended an in-service for reporting Change of Condition and Elopement Behaviors on 01/04/2024. MA G stated she was informed to lock the front door at 6:00 PM with the entrance code posted on the outside of the front door and visitors were to ask for the code when they exited the facility. During an interview on 01/05/2024 at 2:52 PM CNA H (6PM to 6AM shift) stated that she received in-service training o [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident #2) reviewed for 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. The facility failed to: Prevent a medical device (immobilizer brace) from causing unnecessary pressure to Resident #2's right posterior thigh, which caused wound #8, an open lesion to worsen to a Stage III pressure injury and two newly identified areas on the right posterior thigh to form Stage III pressure injuries from a medical device, (Wound #10 on 02/09/22) and (Wound #11 on 02/10/22); resident also was noted to have a pressure injury to the left heel worsen from a Stage II, identified on 02/08/22 to an unstageable on 02/09/22 and increase in size on 02/10/22. These failures had the potential to affect residents by placing them at risk for infection and the development and worsening of pressure ulcers. Findings included: Record review of Resident #2's electronic face sheet dated 02/10/22 revealed she was a [AGE] year old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Quarterly Minimum Data Set (MDS) assessment, dated 12/22/21 revealed in Section C, a BIMS score of 09, which indicated moderate cognitive impairment. Section G revealed that Resident #2 required extensive assistance from two persons for transfers and extensive assistance from one staff for bed mobility, locomotion on and off the unit, dressing, toilet use, personal hygiene, and bathing. Limited Assistance of one staff for eating. G0400 Functional Limitation in Range of Motion revealed Resident #2 had no impairment and used a wheelchair for a mobility device. Section H revealed she was always incontinent of both bowel and bladder. Section J revealed Resident #2 was not receiving any scheduled or PRN pain medication and had not had pain or hurting at any time. Section J revealed one fall with injury that was not major since the Prior Assessment and Section M revealed Resident #2 was at risk for pressure ulcers/injuries but did not have any. M1040 Other Ulcers, Wounds and Skin Problems identified skin tears and moisture associated skin damage was checked. Record review of Resident #2's most recent Significant Change Minimum Data Set (MDS) assessment, dated 01/25/22 revealed in Section C, a BIMS score was not obtained, C1000, revealed Resident #2 had difficulty in new situations and required modified independence. Section G revealed that Resident #2 required extensive assistance from two persons for bed mobility and toilet use; extensive assistance from one staff for locomotion on and off the unit, dressing, eating, personal hygiene and bathing; Limited assistance of two staff members for transfers. Section G0400 Functional Limitation in Range of Motion revealed Resident #2 had an impairment on one side on her lower extremity and used a wheelchair for a mobility device. Section H revealed she was always incontinent of both bowel and bladder. Section J revealed she received scheduled pain medication and PRN pain medication. Pain Presence revealed the Resident did not have pain or hurting at any time. Section J revealed one fall with major injury (01/15/22) since the Prior Assessment and Section M revealed Resident #2 was at risk for pressure ulcers/injuries but did not have any. M1040 Other Ulcers, Wounds and Skin Problems identified open [CONDITION(S)] other than ulcers, rashes, cuts, skin tears and moisture associated skin damage was checked. (This interview is placed here for clarification for the remainder of the tag to identify wound #8 correctly: )In an interview on 02/09/22 at 2:20 pm, LVN B stated that due to a computer malfunction, Resident #2's Wound #8 had an incorrect location documented on the skin assessments, TARs, Care plans and physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's care plan, 01/19/22, revealed the following: .Focus: Resident has open lesion right calf [*thigh] [*thigh] rear (Wound #8) Goal: The resident will have no complications r/t open [CONDITION(S)] through the review date. Interventions: 01/20/22 .Wound #8 open lesion right calf [*thigh] rear: Cleanse with NS, pat dry, apply skin prep, cover with non-adherent pad, wrap with rolling gauze and secure with tape on Tue-Thu-Sat. 01/31/22 .Wound #8 open lesion right calf [*thigh] rear: Cleanse with NS, pat dry, cover with non-adherent pad, wrap with rolling gauze and secure with tape on Mon_Wed_Fri. 02/11/22 .Wound #8 Open lesion right calf Rear: Cleanse with NS, pat dry, apply Skin Prep, cover with 2x2 bordered dressing, then wrap with rolling gauze and secure with tape on Mon_Wed_Fri. one time a day every Mon, Wed, Fri for wound healing .Identify/document potential causative factors and eliminate /resolve where possible .Monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD .weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations . Focus: Resident has been identified at risk for pressure ulcer development or skin breakdown Goal: resident will have intact skin integrity and preventative measures in place x 90 days. Interventions: .01/26/22 Apply Skin Prep to irritation on right knee posterior aspect .Assess skin q day during care and report any redness and/or irritation .assist with turning and repositioning q 2 hours. Use lift/turn sheet as needed . avoid skin to skin contact. Focus: the resident has pressure ulcer development r/t health conditions: Wound #9 left heel, Pressure, Unstageable: .Goal: The resident's Pressure ulcer will show signs of healing and remain free from infection by/through review date Interventions: The resident requires the bed as flat as possible to reduce sheer, 02/10/22 Wound #9 Left Heel, Pressure Unstageable: Clean with NS, pat dry, Apply [MEDICATION(S)] (a honey-based product for the management of wounds and [CONDITION(S)]), then cover with ABD Pad, then wrap with rolled gauze and secure with tape Q day and PRN until resolved. One time a day .Administer treatments as ordered and monitor effectiveness .Assess/record /monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to the MD .Treat pain as per orders prior to treatment/turning etc. to ensure the resident's comfort .Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. Focus: The Resident has a right distal femur fracture r/t fall .Goal: The resident will not develop complications or permanent loss of mobility related to fracture through review date .Interventions: 02/09/22 Check placement of immobilizer daily. Check for any redness, swelling, or skin break down every day and night shift for Femur Fracture RT leg. Focus: The resident has limited physical mobility r/t right Femur dated 01/26/22 Fx .Goal: The resident will remain free of complications related to immobility, including, contractures, thrombus formation, skin breakdown, fall related injury through the next review date. The resident will demonstrate the appropriate use of adaptive device to increase mobility through the review date. Interventions: Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-break down, fall related injury . Record review of Resident #2's Hospital Discharge Orders dated 01/19/22 revealed there was NOT an order to monitor the immobilization brace for Resident #2 or for any type of wound care for Resident #2. Record review of the Braden Scale for Predicting Pressure Sore Risk dated 01/19/22 at 5:40pm by LVN B a score of 16, which indicated Resident #2 was at-risk for pressure sore/injury. Record review of the Readmission assessment dated [DATE] at 5:08pm revealed Resident #2 had an orthotic device/Splint .generalized weakness FX Rt Femur .L. Skin Thin/Fragile Skin. (there were no check marks for Other open areas, skin tears or reddened areas) .P. Summary Additional Information .Rt femur FX. No surgery done for FX, brace in use to RLE .Electronically signed [LVN C] 01/19/22. Record review of Resident #2's electronic nursing progress notes, dated 01/19/22 17:52 (5:52pm) revealed the following entry: Initial skin assessment completed, skin warm and dry to touch, thin and fragile wound #8 open lesion to right thigh posterior aspect with epithelial to wound base, edges attached, surrounding tissue fragile, no drainage, no signs of infection, measurements 1x1cm, bruises to bilateral upper extremity, soft brace to right leg d/t fx of right femur, no other skin issues noted at this time. Author: [LVN B] electronically signed. Record review of Resident #2's Electronic Treatment Administration Record for January and February 2022, printed on 02/10/22 at 10:10am, revealed the following treatments in part: Wound #8-Open Lesion Right Calf [*thigh] Rear Start date: 01/22/22, discontinued on 1/28/22 (changed from Tue, Thu, Sat to Mon, Wed, Fri) new start date: 01/31/22; discontinued on 02/10/22 (changed treatment) new start date and order 02/11/22 Cleanse with NS, pat dry, apply Skin Prep, cover with 2x2 bordered dressing, then wrap with rolling gauze and secure with tape on Mon_Wed_Fri. One time a day every Mon, Wed, Fri for wound healing. Wound #9 Left heel, Pressure Stage 2; Clean with NS, pat dry, Apply Skin Prep let dry and cover with dry dressing Q day and PRN until resolved. One time a day. Start Date: 02/09/22 D/C Date: 02/09/22 2:07pm Wound #9 Left heel, pressure Unstageable Clean with NS, pat dry, Apply [MEDICATION(S)], then Cover with ABD Pad, then wrap with Rolled Gauze and secure with tape Q day and PRN until resolved. One time a day. Start Date 02/10/22 6:00am. Record review of Resident #2's Skin and Wound Evaluation V5.0, dated 02/03/22 revealed the following wound with identification number for Resident #2 in part: Wound #8, evaluation dated 02/03/22 at 9:00am; performed by LVN A, identified an open lesion to the right calf [*thigh], present on admission; unknown length of time wound has been present; wound measurements 1.0cmx1.0cm, depth not applicable; no evidence of infection; additional care: turning/repositioning program .Notes: Wound #8 Right Calf [*thigh], Open lesion: Measures 1x1cm, wound bed red, edges attached, no s/s of infection noted, denies pain at this time. Notifications: Practitioner notified: [Physician A] .Electronically Signed [LVN A] 02/03/22. Record review of Resident #2's electronic physician orders, unsigned, dated 01/19/22 thru 02/210/22, with a printed date of 02/10/22 at 10:46am revealed the following orders in part: Order date: 01/20/22 Start Date: 01/22/22 End Date: 01/28/22 Wound #8 Open Lesion Right calf [*thigh] Rear: Cleanse with NS, pat dry, apply Skin Prep cover with non-adherent pad, wrap with rolling gauze and secure with tape on Tue-Thu-Sat. One time a day every Tue, Thu, Sat for wound healing. Communication Method: Phone Ordered by: Physician A. Order date: 01/28/22 Start Date: 01/31/22 End Date 02/10/22: Wound #8 Open Lesion Right Calf [*thigh] Rear: Cleanse with NS, pat dry, apply Skin Prep, cover with Non-Adherent pad, wrap with rolling gauze and secure with tape on Mon-Wed-Fri. One time a day every Mon, Wed, Fri for wound healing. Communication Method: Verbal Ordered by: Physician A. Order date: 02/08/22 Order Status: Discontinued Start Date: 02/09/22 End Date:02/09/22 Wound #9 Left heel, Pressure Stage 2: Clean with NS, pat dry, Apply SKIN PREP let dry and COVER with DRY Dressing Q day and PRN until resolved one time a day. Communication Method: Verbal Ordered by Physician A. Order date: 02/09/22 Order Status: Active, Start Date: 02/10/22 Wound #9 Left heel, pressure Unstageable Clean with NS, pat dry, Apply [MEDICATION(S)], then Cover with ABD Pad, then wrap with Rolled Gauze and secure with tape Q day and PRN until resolved. One time a day. Communication Method: Verbal, Ordered by Physician A. Order date: 02/10/22 Start Date: 02/11/22 Wound #8 Open Lesion Right Calf [*thigh] Rear: Cleanse with NS, pat dry, apply Skin Prep, cover with 2x2 bordered dressing, then wrap with rolling gauze and secure with tape on Mon_Wed_Fri. One time a day every Mon, Wed, Fri for wound healing. Communication Method: Verbal, Ordered by Physician A. Observation and interview on 02/08/22 at approximately 1:50pm, Resident #2 was lying in bed on her right side. Resident #2 recalled hurting her right leg a few weeks ago and at the time of the interview, denied any pain. In an interview on 02/08/22 at 3:30pm, CNA C said that she cares for Resident #2 regularly and that since she has returned from the hospital and being on the covid unit, she now required two people to transfer her and reposition her; CNA C said that Resident #2 favors her right side; she used a Geri chair now instead of a wheelchair. CNA C said that she has a brace on her right leg to keep it from moving due to having a fractured femur. Record review of Resident #2's Skin and Wound Evaluation V5.0, dated 02/08/22 revealed the following wound with identification number for Resident #2 in part: Wound #9, evaluation dated 02/08/22 at 9:16am, performed by LVN A, identified a Stage II pressure injury to the left heel, acquired in-house; newly identified; measuring 5.5cm x 5.0cm depth not applicable; 50% of epithelial tissue present, no evidence of infection; light amount of exudate; progress, New; Notes: wound #9: left heel, Pressure Stage 2: Measures 5.5x5cm, 50% of epithelial, wound bed red, edges attached, no s/s of infection noted, pain at a 3 during dressing. Practitioner notified; resident responsible party notified .electronically signed [LVN A] 02/08/22. In an interview on 02/09/22 at 10:15am; Resident #2's responsible party said she was aware of the wound to Resident #2's left heel and back of her right leg and some skin tears she has had since her fall. The Responsible Party for Resident #2 said that she had concerns regarding the ill-fitting brace (constantly migrated down her leg after Resident #2 was moved and repositioned) that Resident #2 was having to wear and felt that it could be a better fit. Observation on 02/09/22 at 10:28am, Resident #2 lying in bed in a fetal like position, on her right side; immobilizing brace on right leg, abrasion and redness noted to posterior side of right leg, no bandage present on open wound to right posterior thigh. In an interview on 02/09/22 at 10:29am, CNA B said that physical therapy had worked with Resident #2 this morning after breakfast and put her back to bed; CNA B said she thought wound care had applied a bandage but was not sure what happened or where it went and said that physical therapy had placed resident back in bed. In an interview on 02/09/22 at 11:40am, the DON said that Resident #2 had an immobilization brace on her right leg due to having a femur fracture. The DON said that the immobilization brace should be checked for fit, circulation distal to the brace to ensure it was not too tight; skin integrity underneath the brace; staff should report any skin issues to the physician that ordered the brace and her expectation was nursing staff should put it on the 24-hour report to monitor for charge nurse. The DON verified by checking in the computer at the time of the interview that there was not a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #2 had seen Physician B on 01/27/22 and there were no new orders or concerns with skin integrity or ill fit of the immobilization brace. Record review on 02/23/22 at 4:15pm of Resident #2's physician examination record from follow up visit with Physician B on 01/27/22 revealed the following: Date 1/27/22, [Resident #2], [Physician B], The above named patient was examined by me and or my physician assistant or NP today in our office .non-weight bearing status, no medication changed, no new orders, activity restrictions and a follow up appointment on 02/17/22 at 10:45am, monitor right lower extremity closely for wounds .signed Physician B's Assistant. In an interview on 02/09/22 at 12:03pm, RN A said that she was the charge nurse for Resident #2 and had cared for her regularly since her readmission on 01/19/22. RN A was aware that Resident #2 had an open lesion to her right posterior thigh and felt that it was from the immobilizing brace rubbing on her skin but said that the treatment nurse provided care for her wounds. RN A was unaware that Resident #2 had a wound on her left heel at the time of this interview. RN A said that Resident #2 did favor her right side and staff often attempted to reposition her but Resident #2 would prefer to be on her right side curled up in her bed; RN A said prior to her fall Resident #2 did not walk or get up and about except for meals. RN A said that the treatment nurses would sometimes communicate when there was a new skin issue but not always. RN A said that she gets notified of new skin issues either by the CNAs reporting it to her, reading it in the progress notes in the resident's chart, care plan or the 24-hour report usually will identify anything new with a resident. RN A said that it is the treatment nurses' responsibility to notify the responsible parties and physician when there is a new wound identified. RN A said that she was aware Resident #2 had the immobilization device but there was not a specific order to monitor the brace, but she had been checking pedal pulses and ensured Resident #2 had the brace applied to her right leg. Observation on 02/09/22 at 12:20pm; CNA A and CNA B transferred Resident #2 into her Geri-chair; top of immobilization brace had direct contact with the open lesion on the right posterior thigh, redness also noted to right posterior thigh. Observation and interview on 02/09/22 at 2:20pm; Resident #2 had received a shower by staff; LVN B said that she had just finished performing the treatments for Resident #2, which included a treatment to her Left heel, which started out yesterday (2/8/22) as a Stage II pressure ulcer but now LVN B said that it has been identified as unstageable; LVN B said she also performed treatment to Resident #2's open lesion to her right back thigh and also said there was some excoriation behind her right knee. LVN B stated that she felt the open lesion to Resident #2's right posterior thigh was due to the immobilizer brace and stated it appeared to be digging into her skin. LVN B was unable to say for sure what had made the wound on Resident #2's left heel worsen and at this time asked if it was okay to stop the interview to go and get LVN A for better clarification. In an interview on 02/09/22 at 5:00pm, LVN A said that she had recently been the assigned treatment nurse for Resident #2 and that currently Resident #2 had the following wounds present: A new unstageable pressure injury to her left heel, skin tear to her right lateral calf; and an open lesion to her upper right thigh, close to where the immobilization brace hits the middle of her thigh. LVN A said that she removes the brace on Mondays, Wednesdays and Friday to perform her wound care treatments and monitored for any signs of additional skin break down or skin issues; LVN A said that the brace did not fit great but that is what she came back from the hospital with, and that staff had been trying to keep it pulled up and applied correctly as best that they could, but that sometimes it migrated down Resident #2's right leg. LVN A said that she had not seen an order to monitor the brace and had not contacted Physician B regarding the skin issue on the back of Resident #2's right posterior thigh due to Resident #2 had recently been to see Physician B and that she had admitted from the hospital with the wound so LVN A felt that Physician B was already aware of the wound. LVN A said she does not write anything on the 24-hour report when there is a new skin issue but that it is documented in the chart, progress notes and she will verbally communicate with the charge nurse if there is a new skin issue. Observation and interview on 02/09/22 at 5:22pm revealed Resident #2 lying on right side in a fetal position, Resident #2 denied pain at rest; observation of left heel had dressing intact, left heel was lying directly on mattress, left medial shin lying directly on metal ring that was attached to immobilizer brace; one pillow observed between Resident #2's upper legs. At this time, CNA A and CNA B called LVN A to Resident #2's room during peri-care to report the exposed open area to Resident #2's right posterior thigh. Observation of Resident #2's right posterior thigh revealed the immobilizer brace to be causing pressure to the middle aspect of Resident #2's right posterior thigh. The top part of the immobilizing brace was directly touching the open lesion to the right posterior thigh. Resident #2 verbally denied pain at this time and there was no evidence of facial grimacing or furrowing or brows or tearful observed on Resident #2's face. At this time, LVN A removed the brace and indicated that the dressing had shifted and was no longer protecting the skin as it should be. The metal stay on the back of the immobilizer brace was noted to be directly touching the area that was open and reddened on the right posterior thigh. LVN A assessed the skin and noted there to be an additional wound present on the right posterior thigh that measured 0.4cm x 0.6cm. LVN A performed treatment to both wounds and reapplied the brace high enough on the right leg that it did not appear to apply undue pressure to the right thigh. LVN A said that she wasn't sure what to do because the order for the immobilizer brace was clarified just this afternoon with the ADON and Physician B's office and Resident #2 was supposed to wear the immobilizer brace continuously due to her femur fracture. LVN A said that the immobilizer brace was not able to fit correctly on Resident #2 because the resident liked to keep her leg bent. LVN A was unsure how Resident #2 acquired the unstageable pressure injury to her left heel but felt it was due to her immobility, recent decline. Interview on 02/09/22 at 6:04pm, the DON said that she was unaware that the immobilizer brace was causing skin break down but was aware that the immobilizer brace had been difficult to keep applied in the correct position due to Resident #2 constantly wanting to lie in a fetal position with her right leg bent and the brace would over time migrate downward causing it to fit improperly. In an interview on 02/09/22 at 6:45pm, RN A said that she was not aware of any additional skin issues on the back of Resident #2's right posterior thigh and said that neither LVN A nor LVN B had reported any new skin/wound findings to her today during her shift. Attempted telephone interview on 02/10/22 at 8:45am with Physician B, message left on his assistant's voicemail. In an interview on 02/10/22 at 10:25am, LVN A said everything they (treatment nurses) tried, whether it was rolled gauze as a barrier or ABD pads to protect the skin from the brace would not stay in place and would eventually migrate in a downward position and the ABD pad and rolled gauze would constantly work its way out. LVN A said that she reported Resident #2's left heel wound getting worse to the DON on 02/09/22. LVN A said that she felt it had worsened due to Resident #2 moving her leg around, rubbing at the bed. LVN A said that she was not sure if the mattress Resident #2 was considered a pressure relieving mattress but thought that all the mattresses in the facility were pressure relieving of some kind. LVN A was not sure if the skin injuries to Resident #2 were avoidable but felt that if she didn't have the brace the ones on her right thigh would be healing better. In an interview on 02/10/22 at 10:37am, ADON A said that she oversees Resident #2's care. ADON A said that she was aware Resident #2 had wounds where the top of the immobilizer brace was rubbing on the right posterior thigh but said she had not seen the wounds and that the treatment nurses do not report to her, they report to the DON. ADON A said that the treatment nurses participate in the clinical meetings in the morning where any concerns with resident's care were discussed and that it had been brought up in the clinical meeting earlier this week, however there had not been a clinical meeting this morning as of the time this interview was conducted. ADON A said that the facility has weekly skin meetings that involves the treatment nurses, dietary managers, dieticians, MDS nurses, ADONS and the DON and sometimes the regional nurse, where they discuss any new or worsening wounds that have been identified and collaborate new interventions or ensure proper care is being provided. ADON A said she was not sure the cause of Resident #2's pressure injury to her left heel, it had just recently been identified and there had not been a meeting yet to discuss the wound. ADON A stated she contacted Physician B's office late yesterday afternoon but only to clarify the length of time Resident #2 was required to wear the immobilizer brace. ADON A said that she additionally had contacted Physician B's office this morning (2/10/22) to let them know that she had skin breakdown and to see if they had any additional orders to implement. ADON A said that there is not any documentation specific to a repositioning scheduled, there is documentation where the residents are assisted up for meals, showers, and toileting and that staff just know that everyone has to be repositioned in the facility every two hours. In an interview on 02/10/22 at 11:50am, the DON said that she recalled the last clinical meeting was on 02/08/22 and that LVN A had mentioned Resident #2's new wound on her left heel. The DON said she recalled it did not reflect on the 24-hour report and educated both LVN A and LVN B that if a new skin issue is identified it needs to be placed on the 24-hour report. The DON said that there was not a repositioning schedule or documentation showing residents are repositioned every two hours, specifically Resident #2, but that the CNAs were trained to reposition residents every two hours upon hire and the charge nurse should be walking up and down the halls to ensure that residents are being repositioned. The DON said that if she becomes knowledgeable that a wound has worsened, the treatment is reviewed, notification to the physician is done and the facility also has a specialty company that comes in every week, the dietician is contacted and there is a weekly skin meeting. The DON said that she was notified that Resident #2's wound had worsened on her left heel and is now unstageable and she was recently made aware that there was an additional wound to her posterior right thigh. The DON said that wounds that have worsened or become newly identified are typically discussed in clinical stand-up meeting and brought to a weekly skin/nutrition meeting with an interdisciplinary team to discuss interventions and any new orders necessary; the DON said that given the fact that there was a current investigation being conducted the clinical stand-up meeting had not been conducted and the weekly skin/nutrition meeting was scheduled for the following Tuesday 02/15/22. The DON said that there is an order as of today (02/10/22) in place to get Resident #2 a low air loss mattress, but that all the mattresses in the building are considered to be pressure relieving mattresses and a phone call has been placed to Physician B for clarification on the skin breakdown for Resident #2 and her immobilization device. The DON said that Resident #2's wounds in her opinion were avoidable and were caused by the immobilization brace. Observation and interview on 02/10/22 at 2:34pm of Resident #2, lying in bed on her right side; Resident #2's immobilizer brace in place on right leg, top portion of the immobilizer brace was pressing into the mid aspect of the right posterior thigh with Resident #2's right leg slightly bent, there was a non-bordered foam dressing in place with rolled gauze that had shifted downward; the wound was undressed by the DON and Regional Nurse and upon observation of Wound #8 and Wound #10, there was an additional wound identified to the right posterior thigh distal to the other wounds. The DON immediately removed the immobilizer brace and instructed staff to not reapply the immobilizer brace and the need to contact [Physician B]. Resident #2 denied pain during the procedure. Record review of the 24-hour report for dated 02/08/22-02/10/22; received from the corporate nurse on 02/10/22 at approximately 3:00pm revealed the following: 02/08/22-[Resident #2] 6pm-6am- Geri chair, no w/c. 6am-6pm at baseline. 02/09/22-[Resident #2] 6pm-6am- Blank. 6am-6pm no change. 02/10/22-[Resident #2] 6pm-6am- Baseline 6am-6pm Blank. Record review of the electronic Nurse MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's electronic nursing progress notes, printed on 02/10/22 at 10:38am revealed the following entries: 01/19/22 23:07 (11:07pm) .Resident noted with brace to right lower extremity. Pedal pulses palpable .electronically signed [RN C] 01/20/22 13:38 (1:38pm) .Resident noted with brace to right lower extremity. Pedal pulses palpable .electronically signed [DON]. 01/22/22 09:03 (9:03am) .Brace in use to RLE et RLE elevated with pillow. No redness or s/s irritation noted to surrounding skin .Electronically signed [DON]. 01/24/22 20:16 (8:16pm) .Resident noted with brace to right lower extremity. Pedal pulses palpable . electronically signed [RN C]. 01/26/22 16:59 (4:59pm) .Skin assessment completed, skin warm and dry to touch, thin and fragile .wound #8 open lesion to right calf [*thigh] with scab to wound base, edges attached, surrounding tissue fragile, no drainage, no signs of infection, measurements 1cmx1cm, irritation to knee posterior aspect was noted, skin prep applied, rolling gauze applied, brace to right leg adjusted, no other skin issues noted at this time. Electronically Signed: [LVN B] 01/27/22 20:07 (8:07pm) .Pt had appt. with [Physician B] Ortho and returned with daughter, no new order noted per [Physician B] just a f/u appt. noted and monitor RLE closely for wounds, which TX Nurse is aware of and treating. No weight bearing, continues with fracture to RT femur, monitor for pain and PT [physical therapy] educated CNAs how to transfer properly with x 2 assist on all care and transfers .electronically signed [RN A] 02/09/22 16:06 (4:06pm) .This nurse spoke with [Physician B's assistant], when asked about how long [Resident #2] will continue in the immobilizer, [Physician B's assistant] states she would be in complete extension until her follow up appt on 2/17/22. Then [Physician B] [TRUNCATED]