Every finding on record at Avir at Burkburnett

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:A. Kitchen Aide F wore a hair restraint for his moustache and goatee/beard. B. The shelves throughout the kitchen were clean and not soiled.C. The stove and oven were clean and not soiled with working knobs and all parts working. D. The grease fryer was clean and not soiled with grease buildup.E. The vent hood was clean and free of dust.F. The food cart that drinks were being prepared on was clean and not soiled.G. The food disposal was free of food.H. The food thicker was in a sealed container. These failures could place residents at risk for foodborne illness, compromised nutritional health status, and being served food items that may not be fresh, taste stale, or be contaminated.The findings included:In an observation on 02/17/26 at 9:15 AM, during the initial tour of kitchen, Kitchen Aide F's mustache and goatee/beard was not covered with a hair net. He was preparing drinks for the residents and placing them on a cart that that was soiled with food crumbs on the top of the cart. The shelves throughout the kitchen, including the shelves that held the dishes, pots and pans, were soiled with food crumbs and dust. The bowl attached to the mixer had food crumbs in the bottom of the bowl. The grease fryer had some pieces of fried okra in the basket from the day before and the top of the grease fryer was covered with grease. The stove was missing 3 knobs to turn the burners on, and the stove and oven were soiled with food crumbs and dried food. The vent a hood was covered with a layer of dust. The food disposal had standing food in it. The container that contained food thickener located near the blender was not sealed properly as it had a piece of foil covering the top for the lid. In an interview on 02/19/26 at 2:49 pm, the Dietary Manager said when he came to work yesterday, he noted that Kitchen Aide F did not have his facial hair covered. He said it was his expectation that all facial hair to be covered. The findings concerning the food crumbs and dirt on the shelves and appliances were observed with the Dietary Manager and said he would get it cleaned and fix the issues. The Dietary Manager said the food disposal should be run when food was placed in it. The Dietary Manager said all of his staff are new and they are in the process of training them. The Dietary Manager said the stove was missing some knobs and the griddle portion of the stove top was not working but it had not been a big issue. The Dietary Manager said potential negative outcomes of not keeping crumbs, food, and dirt/dust could attract pests, bad smells, hair in food, and infection control issues. In an interview on 02/19/2026 at 4:15 pm, the Administrator was made aware of findings in kitchen. She said there has been a lot of staff turnovers in the kitchen. It was her expectation for the kitchen to be cleaned after each meal. She was made aware the stove was missing some knobs, and the griddle portion of the stovetop was not working. She said a possible negative outcomes could be pests and infection control. Record review of the facility policy Sanitization, dated as revised November 2022, revealed the following [in part]:Policy Statement: The food service is maintained in a clean and sanitary Manner. Policy Interpretation and Implementation: 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in food repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning.

Based on observation, interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 (Residents #2, #7, and #38) of 5 residents reviewed for treatment administration. The facility failed to ensure staff accurately documented Resident's 2, #7, and #38's Medication Administration Record (MAR) the administration of controlled substance. The facility failed to ensure staff followed up with Resident's #2, #7 and #38 after narcotic pain medication administration for monitoring results and or complaints/symptoms for which the drug was administered, per facility policy. These failures could put residents at risk for medication errors and errors in care.Findings included: Resident #2 Review of Resident #2's face sheet, dated 2/19/2026, revealed the resident was a [AGE] year-old female who originally admitted to the facility on [DATE], with readmission date of 12/18/2023. Her diagnoses included Type 2 Diabetes, non-pressure chronic ulcer of the right foot, and chronic pain syndrome (long term pain). Review of Resident #2's Quarterly MDS, dated [DATE], reflected a pain presence of yes, frequency was occasionally, and it occasionally affects her sleep and day to day activities. Review of Resident #2's care plan, dated 12/05/2025, reflected the following: Insomnia/sleep pattern disturbance . Assess for pain and administer pain meds as ordered. Monitor for effectiveness I am on pain medication therapy related to diagnosis of chronic pain syndrome. Assess/record/report to MD as needed signs/symptoms of distress or pain unrelieved by ordered treatments. Administer analgesic medications as ordered by physician. Monitor for side effects/effectiveness. Review of Resident #2's physician's orders, dated 2/10/2026, revealed the following order:Acetaminophen-Codeine Oral Tablet 300-60 MG Give 1 tablet by mouth every 4 hours as needed for pain -Start Date- 02/10/2026 1000 Review of Resident #2's MAR dated 02/19/2026 verses her Controlled Medication log dated most recently 02/19/2026, revealed the following dates: 2/11/2026 x1 dose, 2/12/2026 x4 doses, 2/13/2026 x2 doses, 2/14/2026 x1dose, 2/15/2026 x3 dose, 2/16/2026 x2 doses, 2/17/2026 x4 doses, 2/18/2026 x3 doses, and 2/19/2026 x1 dose, was not documented in the MAR to show the medication, Acetaminophen-Codiene Oral Tablet 300-60mg, was administered but was only documented as administered on the Controlled Medication log. The log and medication count were correct as of this day, 02/19/2026. Review of Resident #2's Progress Notes dated 2/19/2026 at 15:03pm, with date range of 1/1/2026 thru 2/19/2026, revealed no nursing note or documentation for follow up of effectiveness for Resident #2's pain medication administration. Observation and interview on 2/18/2026 at 9:51am with Resident #2, she was lying in bed watching television, she stated she received her medications on time and if she needed a pain pill the nurses were good about getting it to her. Resident #7 Review of Resident #7's face sheet dated 02/19/2026 reflected she was an [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her diagnoses included Bipolar disorder (a mental health condition), Chronic pain (long term pain), and Anxiety. Review of Resident #7's Quarterly MDS, dated [DATE], reflected the following:Section I0020 Active Diagnoses marked for anxiety disorder.Section J0100 Pain Management - received scheduled pain medication marked yes.Section N0415 High Risk Drug Classes marked for taking Antianxiety and Opioid medications. Review of Resident #7's care plan with revision date 02/03/2026 reflected the following: I am at risk for alteration in comfort/risk for pain presence R/T disease process. I am on pain medication therapy r/t other chronic pain. Administer analgesic medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. I use anti-anxiety medication r/t DX of anxiety disorder. Administer anti-anxiety medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Review of Resident #7's physician orders dated 2/19/2026 revealed the following orders:Acetaminophen-Codeine Oral Tablet 300-30 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain related to Chronic pain. Start date 11/18/2025Hydrocodone-Acetaminophen Oral Tablet 5-325MG Give 1 tablet by mouth every 6 hours as needed for moderate pain related to Chronic pain. Start date 11/19/2025Lorazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth in the evening related to Anxiety. Start date 1/26/2026. Review of Resident #7's MAR dated 02/19/2026 verses her Controlled Medication log dated revealed the following:There was no documentation in Resident #7's MAR of the administration of her Lorazepam Oral Tablet 1mg on the following days for the month of February; 02/04/2026, 02/05/2026, 02/06/2026, 02/07/2026, 02/08/2026, 02/09/2026, 02/10/2026, 02/11/2026, 02/12/2026, 02/13/2026, 02/14/2026, 02/15/2026, 02/16/2026, 02/17/2026, and 02/18/2026. These dates were marked and initialed as administered on Resident #7's Controlled Medication Log. Log and medication count were correct as of this day, 02/19/2026. There was no documentation in Resident #7's MAR of the administration of her Hydrocodone-Acetaminophen Oral Tablet 5-325MG on the following days for the month of February; 02/17/2026 x1 dose. This date was marked and initialed as administered on Resident #7's Controlled Medication Log. The log and medication count were correct as of this day, 02/19/2026. There was no documentation in Resident #7's MAR of the administration of her Acetaminophen-Codeine Oral Tablet 300-30 MG on the following days for the month of February; 02/09/2026 x2 doses, 02/10/2026 x3 doses, 02/11/2026 x3 doses, 02/12/2026 x3 doses, 02/13/2026 x3 doses, 02/14/2026 x3 doses, 02/15/2026 x3 doses, 02/16/2026 x3 doses, 02/17/2026 x3 doses, 02/18/2026 x3 doses, and 02/19/2026 x2 doses. These dates were marked and initialed as administered on Resident #7's Controlled Medication Log. The log and medication count were correct as of this day, 02/19/2026. Review of Resident #7's Progress Notes dated 2/19/2026 at 15:03pm, with date range of 1/1/2026 thru 2/19/2026, revealed no nursing note or documentation for follow up of effectiveness for Resident #7's pain or anxiety medication administration. Observation and interview on 02/18/2026 at 9:51am with Resident #7, she was lying in bed resting in low position, hydration on bedside table, call light within reach. Resident stated she was doing ok, that she had a procedure on her eye yesterday and it was a long day. She stated she had no concerns at this time. She stated she receives her medication on time from what she can tell, that she's never had an issue with receiving her medications. She stated if she needed something for pain the nurse was good at getting it for her. Resident #38 Review of Resident #38's face sheet dated 02/18/2026 revealed he was a [AGE] year-old male admitted on [DATE]. His diagnoses included heart disease, cancer of left ear, and chronic pain (long term pain). Review of Resident #38's MDS dated [DATE], reflected it had not been completed as of 02/19/2026. Review of Resident #38's care plan dated 02/16/2026 reflected the following. I am at risk for alteration in comfort/risk for pain presence related to disease process and diagnosis other chronic pain . Administer pain medications as ordered by physician and assess effectiveness. My physician ordered the opioid medication Hydromorphone related to diagnosis of chronic pain . Administer medication as ordered. Review of Resident #38's physician orders dated 2/19/2026 revealed the following orders:Hydromorphone extended release 15mg capsule Give 1 capsule orally/rectally every 8 hours as needed for Moderate pain related to chronic pain. Start date 02/12/2026. Hydromorphone hydrochloride Oral Tablet 4mg Give 1 tablet by mouth every 4 hours as needed for moderate pain related to chronic pain: malignant melanoma of left ear and external auricular canal. Start date 02/12/2026. Review of Resident #38's MAR dated 02/18/2026 verses his Controlled Medication log dated revealed the following:There was no documentation in Resident #38's MAR of the administration of his Hydromorphone hydrochloride Oral Tablet 4 MG on the following days for the month of February; 02/12/2026 x1 dose, 02/13/2026 x2 doses, 02/14/2026 x1 dose, 02/15/2026 x3 doses, 02/16/2026 x4 doses, 02/17/2026 x3 doses, and 02/18/2026. These dates were marked and initialed as administered on Resident #38's Controlled Medication Log. Log and medication count were correct as of this day, 02/19/2026. There was no documentation in Resident #38's MAR of the administration of his Hydromorphone extended release 15mg capsule Give 1 capsule on the following days for the month of February; 02/13/2026 x1 dose, 02/16/2026 x1 dose, 02/17/2026 x1 dose, and 02/18/2026 x1dose. These dates were marked and initialed as administered on Resident #38's Controlled Medication Log. Log and medication count were correct as of this day, 02/19/2026. Review of Resident #38's Progress Notes dated 2/19/2026 at 15:03pm, with date range of 2/12/2026 through 2/19/2026, revealed no nursing note or documentation for follow up of effectiveness for Resident #38's pain medication administration. Observation and interview on 02/18/2026 at 11:09am, Resident #38 was standing independently in his room, bed made in low position, call light within reach, hydration on bedside table. He stated he was there for rehab and get his medications back on track. He said he only has 15% use of his heart and messed up his medications. He stated he has been with Hospice a while, and that he has ear cancer too. He stated he receives his medications on time but sometimes his pain would be more than the medication would help but Hospice was trying to adjust them best they could for what he needed. In an interview on 02/18/2026 at 3:01 PM with LVN G, she stated she has worked there for almost 3 years. She stated she was fully trained when she was hired and feels competent in her position. She further stated for hospice residents, if the resident came to her a couple hours later after giving him or her pain medication and said it's not working can I have the stronger medication that as long as it was ordered and available to be given at that time she would give it. She said a negative outcome for the residents if not given as ordered would be unnecessary pain and suffering. She also stated when she administers a narcotic pain medication she must log and initial it on the residents narcotic sheet to make sure the count was correct and then document in the residents MAR to show it was given. She stated that was the expectation and a negative outcome could be a medication error. In an interview on 02/19/2026 at 10:15am with LVN A, she stated with all controlled medication administration there was a separate log the nurses and medication aides must complete, date and initial when administering and then they must document in the residents MAR their pain scale and the administration. She further stated they were to follow up with the resident to make sure the effectiveness of the pain meds or any adverse effects. She stated a negative outcome could be a medication error. When asked about the MAR's and logs not correlating for all 3 residents, she stated the only thing she could say about it not being documented in one or the other could just be laziness and not taking the time to document both or forgetting to go back to mark in the MAR. In an interview on 02/19/2026 at 11:00am with the DON, she stated the controlled medication logs were to be filled out when medications were administered and documented in the residents MAR. She stated an adverse outcome could be a drug diversion or medication error. Review of facility provided policy titled Administering Medications dated revised April 2019 revealed [in part]:22. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones.23. As required or indicated for a medication, the individual administering the medication records in the resident's medical record: a. The date and time the medication was administered; f. Any results achieved and when those results were observed;

Based on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #33 and Resident #23) of sixteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #33 on 02/17/2026 and 2/19/2026. The facility failed to ensure the call light was in reach and accessible for Resident #23 on 02/17/2026. This failure could place the residents at risk of being unable to obtain assistance when needed, obtain help in the event of an emergency, and result in an increased risk of falls. Findings included: Resident #33 Review of Resident #33's Face Sheet, dated 5/22/2025, reflected a [AGE] year-old male, admitted on [DATE]. Resident #33 had diagnoses of cerebral infarction (stroke), contracture to left hand (a condition of shortening and hardening of muscles thereby limiting joint mobility), muscle wasting (loss of muscle mass), and left side hemiparesis (weakness or paralysis on one side of the body, often caused by stroke, traumatic, brain injury or tumors, which may affects the arms legs and face). Review of Resident #33's Quarterly MDS Assessment, dated 12/29/2025, reflected that Resident #33 had a BIMS score of 11, indicating moderate cognitive impairment. The Quarterly MDS Assessment also indicated the resident required assistance for toileting, dressing, personal hygiene and transferring. Review of Resident #33's Comprehensive Care Plan, dated 12/13/2025, reflected Resident #33 was a fall risk, and one of the interventions was a reachable call light and to respond quickly to all calls for assistance. Observation and interview on 02/17/2026 from 9:30 a.m. to 9:38 a.m. revealed Resident #33 lying in bed. The call light was observed hanging down at the foot of his bed between the wall and the bed. Resident #33 stated sometimes staff leave the call light where he can't reach it, but stated when he was able to reach it, it usually doesn't take them long to answer him. He stated he can't use his left arm, but he could pull the call light with his right arm to call for help if he could reach it. He stated that if he cannot reach the call light, he just hollers out for someone to come to help him. He then stated he would like his fingernails to be trimmed and asked the surveyor to call for help. Observation on 02/17/2026 at 9:43 AM CNA D answered Resident #33's call light and turned it off at the wall. She asked Resident # 33 what he needed. He stated he wanted LVN A to cut his nails. CNA D stated she would tell LVN A and left the room without making sure the residents' call light was in reach of the resident. The call light remained out of reach and was hanging between Resident #33's bed and wall. Observation on 02/17/2026 at 9:47 AM MA C entered Resident #33's room. She talked with Resident #33, and he told her he was waiting for LVN A to cut his nails because he was diabetic and the aides weren't allowed to cut his nails. MA C repositioned the resident's left arm and adjusted his pillow, so his left arm and hand were elevated. The call light remained out of reach for the resident remaining between the bed and the wall on the left side of the bed. Observation on 02/17/26 at 9:51 AM LVN A entered room to cut Resident #33's fingernails. The call light was between the bed and wall out of Resident #33's reach. Observation on 02/17/2026 at 9:58 AM LVN A moved Resident #33's bed out from the wall to be able to get to residents #33's left hand on the left side of the bed. LVN A continued to file Resident #33's fingernails. LVN A noticed the call light was not in the resident's reach and placed the call light on the resident's bed in reach of Resident #33's right hand before she left the room. Interview on 02/17/2026 at 9:59 AM LVN A stated it was everyone's responsibility to monitor call lights. She stated her expectation was that call lights always remain in reach of the resident. She stated all staff should check to see that the residents' call light was in reach before they left the resident's room. She stated she did not know why 2 other people had entered the room and left and did not make sure the call light was in reach. LVN A stated a negative outcome for the residents would be that the residents would not be able to receive needed care in a timely manner. She stated a call light not in reach of a resident could lead to a fall. Observation for 02/19/26 at 9:15 a.m. Resident #33's call light was not in reach. The call light was hanging between the bed and the wall. Resident stated he did not know how long it had been there. Resident #23 Review of Resident #23's Face Sheet dated 02/19/26 reflected a [AGE] year-old female, admitted [DATE]. Resident #23 had diagnoses of Dementia (decline in cognitive abilities), Alzheimer's Disease (a type of dementia that affects memory, thinking and behavior and slowly destroys a person's memory and thinking skills.), and muscle weakness. Review of Resident #23's Significant Change 1/20/2026 MDS Assessment, dated 3/18/2025 reflected that Resident #23 had a BIMS score of 3, indicating severe cognitive impairment. The Significant Change MDS Assessment indicated that Resident #23 needed supervision or touch assistance with transferring and toileting. She was continent of bowel and bladder. Review of Resident #23's Comprehensive Care Plan dated 01/15/2026 reflected that Resident #23 was a fall risk, and to instruct resident to call for help before getting out of bed and always keep call light visible to resident and in reach. Observation on 02/17/2026 at 10:28 a.m. Resident #23 was in the recliner in her room sleeping and the room was dark. A fall mat by her bed on the opposite side of the room and her call light was laying on a freshly made bed and was not in reach of the resident. Observation on 02/17/2026 in dining room at 12:10 p.m. Resident #23 was still sleepy during lunch. Staff were attempting to feed this resident. Resident did not respond to attempts to interview her. Interview with the DON on 02/19/2026 at 10:30 AM she stated it was her expectation that all staff monitor to ensure that residents call lights were in reach. She stated it was everybody's responsibility to answer call lights and to ensure residents could reach them. She stated she was preparing an in-service on answering call lights and staff should always make sure call lights were in reach of each resident before they left the room. She stated a call light not being in reach of a resident that needed help could result in an injury or a resident not receiving needed care and services. Review of the policy titled Call system, Residents dated revised January 2025 stated in part: Residents are provided with a means to call staff for assistance through communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff for assistance from his/her bed, from toileting bathing facilities and from the floor. Calls for assistance are answered timely. If a resident has a disability that prevents him or her from making use of the call system, an alternate means of communication that is usable for the resident is provided and documented in the care plan.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #22) of 5 residents reviewed for infection control. The facility failed to ensure staff followed infection control practices of washing hands before performing patient care, performing hand hygiene with an alcohol-based hand sanitizer after glove use, and following proper steps for performing peri-care on a male resident (Resident # 22) during incontinent care. These failures could place residents at risk for infection due to improper care practices. Findings included: Record review of Resident #22's face sheet dated 2/19/26, revealed a [AGE] year-old male, with an initial admission date of 08/01/2024, and a most recent admission date of 07/24/25. Resident #22's diagnoses included: retention of urine (failure of the bladder to empty completely), abnormal gait and mobility, pressure area of the sacrum, and diarrhea. Record review of Resident #22's quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 indicating severe cognitive impairment. Review of Section GG - revealed Resident #22 was dependent on staff for all activities of daily living which included toileting hygiene. Review of Section H revealed Resident #22 was also incontinent of bowel and bladder. Record review of Resident #22's care plan dated revised 1/16/26 revealed the following: Focus: I have the potential for skin breakdown/pressure ulcer development related to incontinence, impaired mobility, and disease process. Interventions: Check often for incontinence. Wash, rinse, and dry soiled areas. Change clothing PRN after incontinence episodes. Observe for signs and symptoms of urinary tract infection including frequency, burning, urgency, foul-smelling urine, cloudy urine, blood in urine, fever, and chills. Provide with adult briefs/pull ups/pads and change as needed During an observation on 02/17/2026 at 10:45 a.m. CNA B and MA C entered Resident # 22's Room. CNA B ran his hand through his hair and then donned gloves without performing hand hygiene. MA C used hand sanitizer which was in her pocket and then donned her gloves. CNA B unfastened Resident #22's urine soiled brief and began to perform incontinent care while leaving the soiled brief laying underneath Resident # 22's buttocks. CNA B cleansed the penis and perineal area by cleaning from the rectal area and up the shaft of the penis to the penis head using only one wipe. MA C used another wipe and cleansed the shaft of Resident #22's penis. She changed her gloves and used alcohol-based hand sanitizer before she donned new gloves. CNA B changed gloves and did not use hand sanitizer before turning Resident #22 to his left side to clean the buttocks and the rectal area. CNA B changed gloves again to apply the clean brief to Resident #22 and then disposed of the soiled brief. CNA B gathered the trash into a bag and removed his gloves and placed them in the bag. MA C removed her gloves, placed them in the trash, and used alcohol-based hand sanitizer to perform hand hygiene before leaving the room. CNA B did not perform hand hygiene before leaving the room. During an interview on 02/17/2026 at 10:55a.m, MA C stated that she knew that CNA B did not perform the incontinent care correctly on Resident #22. She stated he did not use hand sanitizer between glove changes, and he cleaned the Resident #22's perineum while wiping from a dirty to a clean area. She stated a negative outcome resulting from not performing incontinent care and proper hand hygiene correctly would be increasing the risk of infection for the resident. During an interview on 02/17/2026 at 11:00 a.m., CNA B stated that he should have washed his hands before patient contact and should have used hand sanitizer between glove changes. He stated that failure to use proper hand hygiene could cause the spread of germs and infection. He stated he did not have any hand sanitizer available when he did the incontinent care. He stated he did not normally carry hand sanitizer in his pocket. He stated there were hand sanitizer dispensers in the hallways. During an interview on 02/19/2026 at 10:55 a.m., the DON said staff were previously trained on hand hygiene including the need to wash hands before and after glove use. She stated it was her expectation that staff follow this training when providing patient care. She stated staff were competency checked annually. The DON said the risk of not performing hand hygiene between glove use was infection control. Review of facility provided policy titled Perineal Care dated 2021, stated in part: Take the wipe in one hand and gently grasp the penis shaft. If the resident is uncircumcised gently pull the foreskin aback and wipe the head of the penis beginning at the urethral opening working outward and away from the penis head (circular motion). Use a new wipe with each stroke. After cleaning is complete gently move the foreskin back to its natural position if uncircumcised. Cleanse the penis shaft with wipe from the top of the shaft towards the rectum, including the scrotum. Using a new wipe with each stroke cleans from the upper part of the leg to the hip. Repeat to the other side and then once from the hip bone to hip bone. Turn the resident over and repeat on the back side. Take off gloves, put them into the trash bag with the soiled brief and wipes, then wash and sanitize your hands. Review of the facility policy titled Handwashing/Hand Hygiene dated 2001, stated in part: The facility considers hand hygiene the primary means to prevent the spread of healthcare associated infections. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene is indicated immediately before touching a resident. After contact with blood body fluid, or contaminated surfaces, after touching a resident, after touching the resident's environment, before moving from work on a soiled body site t a clean body site on the same resident; and immediately after glove removal.

Based on observation, interview and record review, the facility failed to ensure 1 of 31(East Hall room [ROOM NUMBER]) provided a minimum of 80 square feet of floor space per resident, in that: East hall room [ROOM NUMBER] was included in the facility's licensed capacity as a three-bed resident room and did not provide the minimum floor space required per resident. This failure could place residents at risk for restricted movement and limit the amount of resident use equipment and personal effects that could be accommodated in the room.The findings included: Review of the Bed Classifications Form 3740, signed and dated by the facility Administrator on 2/17/2026, revealed resident room [ROOM NUMBER], located on the East Hall, was licensed for three beds and was categorized as Title 18 (Medicare). In an interview on 2/17/2026 at 2:47 PM, the Administrator stated East Hall room [ROOM NUMBER] is considered under licensure as a 3-bed ward but was used for therapy. She stated she wanted to continue the room size waiver that was in effect for the room. Observation on 2/18/2026 at 3:20 PM, accompanied by Life Safety Code surveyor and the facility's Maintenance Director, revealed Room #E15, was used by the therapy department and contained therapy equipment and a desk. Room #E15 was licensed as a 3-bed ward. The room floor space was measured at 221.8 square feet and equaled 73.9 square feet per person.

Based on interviews and record review, the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans.The facility failed to ensure Resident #1's comprehensive care plan described the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being.The facility failed to ensure Resident #1's comprehensive care plan described any specialized services or specialized rehabilitative services the nursing facility will provide because of PASARR recommendations.The facility failed to ensure Resident #1's comprehensive care plan described the resident's goal for admission and desired outcomes.The facility failed to ensure Resident #1's comprehensive care plan described the resident's preference for future discharge.This failure could place the residents at risk of inadequate care and services.Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male, admission date 11/26/2025, Diagnoses: Spastic Quadriplegic Cerebral Palsy (significant muscle stiffness and poor motor control in all four limbs due to damage to the brain), Spina Bifida (spine doesn't close completely affecting spine and nerves), Recurrent Depressive Disorders (multiple episodes of depression over time by persistent sadness, loss of interest), Protein-Calorie Malnutrition (insufficient intake of protein calories leading to poor growth). Record review of Resident #1's electronic health record revealed no evidence of a comprehensive care plan. Record review of Resident #1's comprehensive MDS dated [DATE], reflected Resident #1's PASARR conditions found were positive. BIMS of 11 (moderate cognitive impairment). In an interview on 01/04/26 at 2:12 p.m. with CNA A, she stated she was familiar with Resident #1's care because he can tell staff what he wants and needs and how he prefers things to be done. CNA A also stated that staff communicate across shifts through verbal reports to make sure the resident gets what he needs to be kept safe. CNA A was knowledgeable about Resident #1's care. In an interview on 01/04/26 at 5:59 p.m. with Resident #1, he revealed he was safe, and he had not gotten hurt while at the nursing facility. He stated that staff care for him the way he tells them to, and he did not have any issues with anything. Resident #1 stated he received his PASARR services and staff were following his plan of care. In an interview on 01/05/26 at 11:57 a.m. with the ADM, she stated that she did not locate a comprehensive care plan for Resident #1. In an interview on 01/05/26 at 12:18 p.m. with the DON, she stated the Baseline Care Plan dated 11/26/25 was the care plan for Resident #1 and no comprehensive care plan had been completed. In an interview on 01/05/26 at 12:30 p.m. with MDS, she stated that she was responsible for completing the care plans after the MDS assessment was completed. She stated that a new company took over the facility, and they have switched healthcare software. MDS stated she had to put in each individual resident's care plan into the software program, and she had not gotten to Resident #1's Care Plan yet. MDS stated staff are aware of Resident #1's needs and know how to care for him. MDS stated Resident #1 was receiving his services despite the care plan not being completed yet. She stated that the facility lost staff, and she was also helping with patient care as a floor nurse. MDS did not state negative effects to residents. In an interview on 01/05/26 at 1:13 p.m. with the ADM, she stated that it was the responsibility of the MDS nurse to complete the assessment and then do the care plan. The ADM stated with the new company transition, the MDS got bogged down. The ADM stated that Resident #1 was receiving his services. The LIDDA was taking him out weekly and they were working on finding him a group home in his preferred location, which is something discussed during his IDT meeting. The ADM stated that the care plan not being completed could negatively affect a resident by them not getting something they need but in Resident #1's case, that was not happening. In an interview on 01/05/26 at 2:15 p.m. with the ADON, she stated that it was the responsibility of MDS to complete the care plan after she does the assessment, and she does not think it is anyone but her is responsible, even if she gets busy. The ADON stated that staff communicate through verbal reports to provide care. The ADON stated if a care plan did not get completed, it could cause injury or an error if interventions were not used. Record Review of the Comprehensive Care Planning policy dated March 2022 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including: (1) services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment; (2) any specialized services to be provided as a result of PASARR recommendations; and (3) which professional services are responsible for each element of care; c. includes the resident's stated goals upon admission and desired outcomes; d. builds on the resident's strengths; and e. reflects currently recognized standards of practice for problem areas and conditions. The policy further reflects, 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.

Based on interviews and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan was developed within 7 days after the MDS assessment was completed. This failure could result in the residents not receiving proper care and services.Record review of Resident #1's face sheet revealed a [AGE] year-old male, admission date 11/26/2025, Diagnoses: Spastic Quadriplegic Cerebral Palsy (significant muscle stiffness and poor motor control in all four limbs due to damage to the brain), Spina Bifida (spine doesn't close completely affecting spine and nerves), Recurrent Depressive Disorders (multiple episodes of depression over time by persistent sadness, loss of interest), Protein-Calorie Malnutrition (insufficient intake of protein calories leading to poor growth). Record review of Resident #1's comprehensive MDS dated [DATE] reflected this was a nursing home comprehensive assessment with PASARR positive and a BIMS of 11 (moderately cognitively impaired). In an interview on 01/05/26 at 12:30 p.m. with MDS, she stated that she was responsible for completing the care plans after the MDS assessment was completed. MDS stated she was aware the Comprehensive Care Plan was to be completed within 7 days of the MDS assessment being completed. She stated that a new company took over the facility, and they have switched healthcare software. MDS stated she had to put in each individual resident's care plan into the software program, and she had not gotten to Resident #1's Care Plan yet. MDS stated Resident #1 was receiving his services despite the care plan not being completed yet. MDS did not state negative effects to residents. In an interview on 01/05/26 at 1:13 p.m. with the ADM, she stated that it was the responsibility of the MDS nurse to complete the MDS assessment and then do the comprehensive care plan. The ADM stated she was aware the care plan was to be completed within 7 days of the assessment, and this did not usually happen but with the new company transition, the MDS got bogged down. The ADM stated that Resident #1 was receiving his services. The ADM stated that the care plan not being completed could negatively affect a resident by them not getting something they need but in Resident #1's case, that was not happening. In an interview on 01/05/26 at 2:15 p.m. with ADON, she stated that it was the responsibility of MDS to complete the care plan after she does the assessment, and she does not think it is anyone but her even if she gets busy. ADON stated that staff communicate through verbal reports to provide care. The ADON stated if a care plan did not get completed, it could cause injury or an error if interventions were not used. Record review of the Comprehensive Care Planning policy dated March 2022 reflected, 2. The comprehensive, person-centered care plan is to be developed within seven (7) days of the completion of the required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21 days after admission.

Based on observation, interview, and record review, the facility failed to ensure a medication error rate are not greater than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Resident #8. 1.LVN A failed to follow physician's order when she flushed Resident #8's PICC line with Heparin flush (blood thinner) 5 ml of 10u/ml. 2.LVN A failed to administer Meropenem ordered by physician for Resident #8 within time frame ordered. These failures could place residents at risk of medication side effects from not receiving their medications as prescribed according to physician's orders and manufacturers recommendations. The finding included: Review of Resident #8's face sheet dated 12/12/24 reflected a [AGE] year-old female male admitted to the facility on [DATE] with most recurrent readmission on 10/19/24 with the following diagnoses: Osteomyelitis (bone infection) right great toe, atrial fibrillation (irregular heart rate). Record review of Resident #8's order listing report dated 12/12/2024 indicated: oOrdered 11/22/2024 Meropenem reconstitute solution; 500 mg; intravenous; Three Times A Day at 6:00am, 12:00pm and 6:00pm. oOrdered 11/22/2024 Flush Central Line Lumen with 10ml of Normal Saline before and after each administration of IV medication or fluids. Every Shift oOrdered 11/22/2024 Flush each Lumen of Central Line with 10ml of Normal Saline every 8 Hours. There was no physician order for Heparin flush for Resident #8. Observation on 12/10/24 at 12:03 PM revealed LVN A entered Resident #8's room to disconnect IV antibiotic (Meropenem). Upon disconnecting IV from PICC, LVN A administered normal saline flush 10ml then administered Heparin flush 6ml via PICC line to right arm. Observation on 12/11/24 at 1:31 PM revealed LVN A administered Meropenem 500mg IV via PICC. Medication Reconciliation review on 12/11/24 revealed 25 opportunities with 2 medication errors. This resulted in an 8 percent medication error rate. In an interview on 12/10/24 at 12:06 PM LVN A stated, I just gave saline flush 10 cc and then cleaned it and gave Heparin flush 6 ml, which is what was in the syringe. She further stated that she had already clicked it off on the screen and was unable to show surveyor order on her screen. In an interview on 12/11/2024 at 1:58pm LVN A stated Meropenem ordered to be started at 12:00p was not started until 1:31pm. LVN A stated that medication was given late due to being busy and she was waiting on Resident #8 to finish lunch. LVNA stated Our normal protocol is SASH method (saline, antibiotic, saline and heparin flush). She further stated that she didn't recall the physician order for heparin flush that was given to Resident #8 the previous day. She stated the expectation for medication administration is to review the MAR and medications before giving. She stated that administering a medication to a resident without a physician's order could cause an adverse reaction, specifically, in this case, redness or bleeding from PICC line. Observation on 12/11/24 at 4:09 PM of medication cart on east hall revealed Heparin flush Lock Flush solution 50 units/5ml with each syringe having 6ml in syringe. There was no pharmacy label on the Heparin flush that included a resident name or directions. In an interview on 12/11/24 at 4:16 PM with the Medical Director regarding heparin flush being used in SASH method after PICC IV antibiotic infusion for Resident #8, he stated I did not order that. I was not aware. He stated that administration of heparin flush in PICC is always a risk of bleeding. He stated his expectation is that a nurse should not administer anything without an order and doing so could cause harm. In an interview on 12/11/24 at 4:44 PM with RNC she stated that her expectation for medication I expect them (facility staff) to check the physician orders, make sure nothing has changed, I expect orders to be checked and followed. I expect for them to be given within the time frame unless the resident is requesting different. She further stated, I probably don't have a specific administration thru a PICC line policy, they should the generalized IV medication administration policy. She stated that there are no standing orders for PICC lines, nor is the SASH method (saline, antibiotic, saline and heparin flush) facility protocol. She further stated that her expectation is not to administer a medication like heparin flush without an order. She further stated that she expects the physician to be contacted. She stated an Adverse outcome of Resident receiving heparin flush without order the resident could have issues with her blood clotting. She stated that she was not aware that heparin flush was administered. She verified that the heparin flush prefilled syringe on the medication cart had 6ml per syringe after opening a flush from the bag and viewing in front of surveyor. Record review of LVN A personnel file revealed Validation Checklist for Flushing and Locking Central Venous Access/Midline/PICC Catheter dated 9/12/24 revealed that nurse was satisfactory in procedure observed and included Reviewed care plan and orders and Lock CVAD 's with either preservative-free 0.9% sodium chloride or heparin flush 10units/ml (or according to manufacturer's directions). Record Review of facility policy Specific Medication Administration Procedures dated 6/1/22 revealed the following [in-part]: Policy: To administer medications in a safe and effective manner. Procedures: C. Review 5 Rights (3) times: 1.Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR for order. b. Note any allergies or contraindications the resident may have prior to drug administration. C .If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. d. Check for vital signs, other tests to be done during/prior to medication administration. e. Prepare resident for medication administration. 2.Prior to removing the medication from the container a. Check the label against the order on the MAR. Review of National Library of Medicine, https://www.ncbi.nlm.nih.gov/books/NBK560654/ , dated 09/04/23 titled Nursing Rights of Medication Administration revealed the following [in-part]: The five traditional rights in the traditional sequence include: 1.Right patient - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. 2.Right drug - ensuring that the medication to be administered is identical to the drug name that was prescribed. 3.Right Route - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. Some common routes include oral, intramuscular, intravenous, topical, or subcutaneous injection. 4.Right time - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. A guiding principle of this 'right' is that medications should be prescribed as closely to the time as possible, and nurses should not deviate from this time by more than half an hour to avoid consequences such as altering bioavailability or other chemical mechanisms. 5.Right dose - Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. Record review of Drugs.com accessed on 12/18/24 at Heparin flush Uses, Side Effects & Warnings revealed in part: Heparin flush is used to flush (clean out) an intravenous (IV) catheter, which helps prevent blockage in the tube after you have received an IV infusion Heparin flush is injected directly into the catheter lock of your IV (intravenous) line. You may be shown how to use heparin flush at home. Do not use heparin flush if you do not fully understand how to flush your IV line and properly dispose of used needles, IV tubing, and other items used to inject your medicines. Follow your doctor's instructions. Record review of Drugs.com access on 12/18/24 at https://www.drugs.com/mtm/meropenem.html revealed in part: Meropenem is an antibiotic that is used to treat bacterial infections of the skin and stomach in adults and children at least 3 months old . Meropenem may also be used for purposes not listed in this medication guide . Follow all directions on your prescription label and read all medication guides or instruction sheets. Use the medicine exactly as directed . Prepare an injection only when you are ready to give it . Skipping doses could make your infection resistant to medication . Avoid missing doses and complete the entire course of therapy. Record review of the National Library of Medicine, accessed on 12/23/24 at https://pubmed.ncbi.nlm.nih.gov/7648757/#:~:text=Plasma%20meropenem%20concentrations%20reach%20a%20peak%20%28Cmax%29%20of,concentration-time%20curve%20increases%20linearly%20in%20a%20dose-related%20manner revealed in part: Plasma meropenem concentrations reach a peak (Cmax) of approximately 30 mg/L after administration of a standard dose of 1 g intravenously. The elimination half-life (t1/2) is approximately 1 hour

Based on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents reviewed for medication administration. (Resident #8). LVN A failed to follow physicians orders when she flushed Resident #8's PICC line with Heparin flush (blood thinner) 6 ml of 10u/ml. This failure could place residents Resident #8 at risk of their health and safety being jeopardized. Findings included: Record review of Resident #8's admission record dated 12/11/2024 indicated she was a [AGE] year-old female originally admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis of Other acute osteomyelitis (bone infection), other site - Right Great Toe. Record review of Resident #8's physician's order report dated 12/11/2024 indicated that she was not prescribed Heparin flush 50units/5ml via PICC. Record review of Resident #8's care plan dated, 11/22/204 indicated [in part]: Problem: Infection Alert - Osteomyelitis of Right Great Toe. Goal: Resolve infection. Interventions: Infection control per protocol. Meds as ordered. Monitor for S/S of infection. Monitor wound/lesion status and progress. VS every shift. Observation on 12/10/24 at 12:03 PM revealed LVN A entered Resident #8's room to disconnect IV antibiotic (Meropenem). Upon disconnecting IV from PICC, LVN A administered normal saline flush 10ml then administered Heparin flush 6ml via PICC line to right arm. In an interview on 12/10/24 at 12:06 PM LVN A stated, I just gave saline flush 10 cc and then cleaned it and gave Heparin flush 6 ml, which is what was in the syringe. She further stated that she had already clicked it off on the screen and was unable to show surveyor order on her screen. In an interview on 12/11/24 at 1:58 PM LVNA stated Our normal protocol is SASH method (saline, antibiotic, saline and heparin flush). She further stated that she didn't recall the physician order for heparin flush that was given to Resident #8 the previous day. She stated the expectation for medication administration is to review the MAR and medications before giving. She stated that administering a medication to a resident without a physician's order could cause an adverse reaction, specifically, in this case, redness or bleeding from PICC line. Observation on 12/11/24 at 4:09 PM of medication cart on east hall revealed Heparin flush Lock Flush solution 50 units/5ml with each syringe having 6ml in syringe. There was no pharmacy label on the Heparin flush that included a resident name or directions. In an interview on 12/11/24 at 4:16 PM with the Medical Director regarding heparin flush being used in SASH method after PICC IV antibiotic infusion for Resident #8, he stated I did not order that. I was not aware. He stated that administration of heparin flush in PICC is always a risk of bleeding. He stated his expectation is that a nurse should not administer anything without an order and doing so could cause harm. In an interview on 12/11/24 at 4:44 PM with RNC she stated that her expectation for medication I expect them (facility staff) to check the physician orders, make sure nothing has changed, I expect orders to be checked and followed. I expect for them to be given within the time frame unless the resident is requesting different. She further stated, I probably don't have a specific administration thru a PICC line policy, they should the generalized IV medication administration policy. She stated that there are no standing orders for PICC lines, nor is the SASH method (saline, antibiotic, saline and heparin flush) facility protocol. She further stated that her expectation is not to administer a medication like heparin flush without an order. She further stated that she expects the physician to be contacted. She stated an Adverse outcome of Resident receiving heparin flush without order the resident could have issues with her blood clotting. She stated that she was not aware that heparin flush was administered. She verified that the heparin flush prefilled syringe on the medication cart had 6ml per syringe. In a telephone interview on 12/12/24 at 10:07 AM with Pharmacist, he stated that the pharmacy only sends Heparin flushes if it is specifically ordered for a resident by a physician or for the facility's emergency kit. He stated a staff member would need an order to access medication in emergency, and that would be patient specific. In an interview on 12/12/24 at 4:28 PM ADM stated that medications are to be given only with a physician's order. The ADM stated that an allergic reaction could be an adverse outcome of giving someone a medication without a physician order. Record review of LVN A personnel file revealed Validation Checklist for Flushing and Locking Central Venous Access/Midline/PICC Catheter dated 9/12/24 revealed that nurse was satisfactory in procedure observed and included Reviewed care plan and orders and Lock CVAD's with either preservative-free 0.9% sodium chloride or heparin flush 10units/ml (or according to manufacturer's directions). Record review of facility policy, Specific Medication Administration Procedure, dated 06/21/2022 indicated the following [in part]: C. Review 5 Rights (3) times: 1. Prior to removing the medication package/container from the cart/drawer; a. Check MAR/TAR for order. b. Note any allergies or contraindications the resident may have prior to drug administration. c. If unfamiliar with the medication, consult a drug reference, manufacturer package insert, or pharmacist for more information. d. Check for vital signs, other tests to be done during/prior to medication administration. e. Prepare resident for medication administration. 2. Prior to removing the medication from the container a. Check the label against the order on the MAR. b. Note any supplemental labeling that applies (fractional tablet, multiple tablets, volume of liquid, shake well, give with another medication, etc.). c. Due to the complexity and length/amount of instructions, some medications may be labeled use as directed. Refer to the MAR for instruction details. Record review of Drugs.com accessed on 12/18/24 at Heparin flush Uses, Side Effects & Warnings revealed in part: Heparin flush is used to flush (clean out) an intravenous (IV) catheter, which helps prevent blockage in the tube after you have received an IV infusion Heparin flush is injected directly into the catheter lock of your IV (intravenous) line. You may be shown how to use heparin flush at home. Do not use heparin flush if you do not fully understand how to flush your IV line and properly dispose of used needles, IV tubing, and other items used to inject your medicines. Follow your doctor's instructions.

Based on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts observed for medication storage. The facility did not ensure the East Hall Medication Cart was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them. Findings included: Observation on 12/10/2024 at 11:38 AM revealed the medication cart for east hall was found unlocked, lock was in unlock position, with the drawers easily opened by hand, parked in the hallway outside of a resident's room. There was no nurse in line of sight of medication cart. The medication cart was unattended. LVN A was in a resident's room and unable to see the medication cart. Medications in the cart included prescription medications, over the counter medications and narcotics. A resident was within 6 feet of medication cart in hallway. In an interview on 12/10/2024 at 11:40 AM LVN A stated she that she had forgotten to lock the medication cart when she went into a resident's room to administer medications. She also stated that she could not see the cart from inside the resident's room. She further stated that the medication cart is to be locked at all times when not in use by the nurse. She continued to state that lack of medication cart security could allow other residents access to the cart and the ability for residents to take medications. LVN A stated that she is responsible for security of her assigned medication cart. In an interview on 12/11/2024 at 4:44 PM RNC revealed that her expectation is for medication carts to be locked if not in use by nurse. She further stated that lack of cart security could allow any resident and/or staff to have access to the medications and contents of cart that are not prescribed to them. RNC stated that the nurse assigned to the medication cart is responsible for security. Record review of facility policy Specific Medication Administration Procedures dated 6/1/2022 revealed the following [in-part]: Procedures: A. Security: All medication storage areas (carts, medication rooms, central supply) are locked at all times unless in use and under the direct observation of the medication nurse/aide.

Based on observation, interview and record review, the facility failed to ensure 1 of 31(East Hall room [ROOM NUMBER]) provided a minimum of 80 square feet of floor space per resident, in that: East hall room [ROOM NUMBER] was included in the facility's licensed capacity as a three-bed resident room and did not provide the minimum floor space required per resident. This failure could place residents at risk for restricted movement and limit the amount of resident use equipment and personal effects that could be accommodated in the room. The findings included: Review of the Bed Classifications Form 3740, signed and dated by the facility Administrator on 12/10/24, revealed resident room [ROOM NUMBER], located on the East Hall, was licensed for three beds and was categorized as Title 18 (Medicare). In an interview on 12/10/24 at 12:47 PM, the Administrator stated East Hall room [ROOM NUMBER] is considered under licensure as a 3-bed ward but is used for therapy, was a 3-bed ward. She stated she wanted to continue the room size waiver that was in effect for the room. Observation on 12/12/24 at 10:20 AM, accompanied by Life Safety Code surveyor and the facility's Maintenance Director, revealed Room #E15, was used by the therapy department and contained therapy equipment and a desk. Room #E15 is licensed as a 3-bed ward. The room floor space was measured at 221.8 square feet and equaled 73.9 square feet per person.

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 7 (Residents #1) residents reviewed for pressure injuries. The facility failed to notify Resident #1's Physician, Resident Representative and Hospice services after identification of wound on Resident #1's right heel. The facility failed to obtain orders for wound care for Resident #1's right heel. The facility failed to perform routine wound care for Resident #1's right heel. The facility failed to complete weekly skin assessments for Resident #1. This failure could place residents who had pressure injuries at risk for new development or worsening of existing pressure injuries. Findings included: Record review of Resident #1's admission record revealed she was [AGE] years old. She was admitted to the facility on [DATE] with a primary diagnosis of dementia with other behavioral disturbances (loss of memory, language, problem solving and other thinking abilities that occurs with agitation and aggressive behaviors), senile degeneration of the brain (mental deterioration), bipolar (mood swings ranging from depressive lows to manic highs), Post-traumatic stress disorder (disorder that results in the person having difficulty recovering after experiencing or witnessing an event), and anxiety (feeling of fear, dread and uneasiness). Record review of Residents #1's Significant Change MDS dated [DATE] revealed the following: -Section C (Cognitive Patterns) reflected a BIMS (Brief interview of Mental Status) score of 07, which is indictive of severe cognitive impairment. -Section M (Skin Conditions) The resident was a high risk for developing a pressure injury but did not have a pressure injury. Record review of Resident #1's care plan dated 02/02/2024 revealed the following: -Pressure Ulcer/Injury- Resident is at risk for skin breakdown related to incontinence and thin fragile skin. Goal- Prevent/heal pressure sores and skin breakdown. Approach- Follow facility skin care protocol, preventative measures: area blank, report to charge nurse any redness or skin breakdown immediately and turn while repositing per resident request. -Cognitive loss/dementia- Resident has dementia. Goal- Resident will be alert and oriented as possible. Approach- Anticipate needs and observe for non-verbal cues, approach in a calm manner, explain what you intend to do while providing care, introduce yourself and orient to person, place and time. -Delirium- Resident has difficulty focusing, easily distracted, and has disorganized thinking. Goal- Resident will be as alert and oriented as possible. Approach- Assess for pain, minimize distraction, and orient PRN. Record review of Resident #1's Weekly skin assessments under Wound Management for Resident #1 indicated on: 03/04/2024 - The right heel was a 6 cm x 6 cm, stage 1, no exudate amount and the tissue were closed and resurfaced. Assessment was completed by LVN #1. 04/07/2024- The right heel was a 1.4 cm x1.7 cm, unstageable, moderate bloody amount of exudate and the tissue was granulated, with 95% granulated and 5% slough. Assessment was completed by LVN #1. There were no documented weekly skin assessments for the week of 03/11/2024, 03/18/2024, 03/25/2024 or 04/01/2024. Record review of Resident #1's Nursing Documentation from 02/01/2024 to 04/08/2024 revealed 04/08/2024 at 9:49 PM., by LVN #1, resident was assessed in house by Hospice RN. Received the following wound care orders: . Right Heel. cleanse with wound cleanser then pat dry with gauze. Apply hydrogel to wound bed. cover with hydro cellular foam dressing. change daily and PRN. No documentation of Physician, Resident Representative or Hospice Services notification of pressure injury identification or decline prior to this date. Record review of Resident #1's Physician Orders dated 04/08/2024 revealed 04/08/2024 at 11:27 AM revealed the following: call placed to hospice. informed need order for wound to right foot. new order received clean with NS, pat dry cover with foam dressing may wrap with gauze if need for comfort. Hospice stated new orders will be given when res is seen by hospice nurse this week, signed ADON. No orders for wound care prior to this date regarding Resident #1's pressure injury to right heel. During an observation and interview on 04/08/2024 at 10:00 AM., Resident #1 was sitting in her wheelchair with socks on both of her feet. She was unsure how long she had the pressure injury in her right foot. She had a gauze wrap around the foot, and she said she wrapped it herself. It was loose and twisted. There was no time, date or initials located on the dressing. She said it had been cleaned yesterday by LVN #1, but that was the first time she had received treatment. She said she has been cleaning it and rewrapping it herself. During an observation and interview on 04/08/2024 at 11:00 AM., the ADON uncovered Resident #1's right foot bandage and completed a skin assessment on the resident. She revealed that she reviewed the resident's chart and that there showed to be no ongoing skin integrity issues on the resident's right foot, as well as orders or treatments. She measured the right foot and reported that the foot had a 5cm x 5cm unstageable ulcer on it. There was a large ring around wound that had dry white pealing skin, small amount of eschar (black tissue) around some edges of the dry peeling skin. In the central portion of the right heal wound was a smaller open area with red beefy appearance and small amount of yellow tissue. Resident had yellow staining on foot that extended through the arch of her foot. She guessed it was unstageable since there was eschar on the border of the heel wound. She said that this was the first time she was made aware that the resident had any pressure related injuries on her right foot and that if she had been made aware, she would have made sure it was assessed weekly, orders were entered, and treatments were completed daily. She stated that she was responsible for the skin care assessments and the weekly observations were missed because she had not checked to see if they were completed by the nurse's that worked the floor. She stated that this task had been delegated to her by the DON since she started in 2023. She stated that Resident #1 should have had orders entered on 03/04/2024 and that the DON, physician, family, and hospice provider should have been notified. She revealed that she was not aware that an initial observation of the wound was documented on 03/04/3024 or that a subsequent observation was completed on 04/07/2024. She performed Resident #1's wound care by cleaning the area and patting it dry, she then covered the area with the bandage and said that she was going to notify the physician and hospice immediately. During an interview on 04/08/2024 at 11:45 AM., the Medical Director revealed that he saw the resident over the weekend when he was completing his rounds and that he did not document the wound or observe the wound, since he was not made aware that the resident had a wound on her right foot. He stated that his expectations were to be notified anytime there is a change in condition, or for another physician to be notified, as well as hospice and the family. He stated that orders and treatment should have been completed and conducted since it was identified on 03/04/2024. He stated that Resident #1 was frequently confused. He stated that this failure could result in the pressure injury worsening from lack of treatment. During an interview and observation on 04/08/2024 at 12:15 PM., Resident #1 stated that she could do most things herself and that she did not need help with things. She did keep her foot clean, and she wore the pressure reducing boot that the facility provided for her. Resident was wearing a pressure reducing boot, blue in color and appeared clean. Resident stated that when she needed wound stuff done or she did not have a bandage, she would use toilet paper to make a pad and just wrap it back up with the gauze that was on it. The gauze appeared clean and not reused multiple times. Resident reported that she was often confused but she knows about her feet. Resident stated that she did not have any other foot issues. Resident stated the orange colored (betadine) stain on her right foot was due to it being cleaned by her. She was unsure and could not remember where she kept or stored the cleaner and that it must be locked up at her nurses' station. During an interview and observation on 04/08/2024 at 1:15 PM., Resident #1 had a pressure reducing boot on her right foot. She reported that the orange that was on her right foot was from when the ADON took off the bandage and put a cleaning solution on it. She did not remember where the cleanser came from or how she obtained it, she thought a nurse gave it to her. She said that she sometimes used tissue paper for the bandage, but she was not sure when. She said that the facility provided her a boot to wear on her feet, but she was unsure who gave it to her or when she wore it. During an interview on 04/08/2024 at 1:30 PM., RN#1 (hospice nurse for Resident #1) revealed that they did not have anything in their records that reflected any type of skin integrity issues or pressure ulcers on foot. She reported that there was no documentation in their records that revealed a call from the facility to let them know that a wound had been identified until that date. She reported that she was going to send an RN out to the facility to access wounds and obtained orders and treatments. During an interview on 04/08/2024 at 2:00 PM., CNA #1 revealed that she was a CNA that provided care for Resident #1. She stated that she knew that Resident #1 had a wound on her foot, but that it had been scabbed over. She revealed that the scab had just come off and that she believed it was being treated, but did not know who was treating it, or how it was treated or when it is treated. She believes had notified the nurse, but she could not remember which one or when she did. She revealed that she has not been treating it. During an interview on 04/08/2024 at 1:20 PM., Resident #2 revealed that she was the roommate of Resident #1. She said that Resident #1 wore a pressure reducing boot at times, but she was unsure who brought it. She stated that the moon boot just appeared one day. She reported that the resident would get up at times and walk. She said that she had seen a nurse provide care for her foot a few times, but she did not know her name. During an interview on 04/08/2024 at 2:10 PM., Resident #2 stated that she had not seen Resident #1 perform wound care on her own feet. During an interview on 04/09/2024 at 4:00 PM., CNA #2 from Hospice revealed she has been giving Resident #1 showers three times a week. She stated she had not been performing wound care on her feet, but that she had been keeping them clean. She stated that she was unaware if there was or was not orders for wound care. During an interview on 04/10/2024 at 2:00 PM., the ADON stated that she was the one that contacted hospice on Monday, 04/08/2024. She revealed that she was responsible for the weekly skin checks on all the residents, including Resident #1. She revealed that she previously had the black area but that it came off the around the 5th, 6th or 7th. She stated that she assumed that the DON was notified initially that Resident #1 had a pressure ulcer injury on 03/04/2024. She revealed that the resident was often confused and unaware of her limitations. She stated that Resident #1 had worn a pressure reducing moon boot for a few weeks, but she was unsure where it came from, she assumed it was from hospice. During an interview on 04/10/2024 at 2:30 PM., LVN #1, revealed that she had been providing wound care on the days she worked. She stated that there were no orders for wound care, so she just guessed and did what she thought it needed. She stated that she was the one who initially identified the wound on her right heel, but that she told it to the nurse who was taking over. She revealed that she did not tell the DON, call the DR, call the family, call the ADON, or call the hospice agency, and that she knew of the process of notification once a change of condition had been identified. She stated that she had not completed the weekly skin assessments, as ordered, because she got busy. She revealed that this failure could result in her pressure ulcers getting worse. Record review of the facilities policy titled Pressure Injury/Skin Breakdown- Clinical Protocol, dated May 2022, revealed the following: Assessment and Recognition: 1) The nursing staff or practitioner will assess and document an individual significant risk factors for developing pressure injuries; for example, immobility, recent weight loss, and a history of pressure injuries. 2) In addition, the nurse shall describe and document/report the following: A) Full assessment of pressure injury including location, stage, link, width and depth, presence of exudates or necrotic tissue. B) Pain assessment. C) Resident's mobility status. D) Current treatments, including support services and E) All active diagnosis. Treatment: 1) The staff will request physicians orders pertinent to wound treatments in medical interventions. Monitoring: 1) during resident visits, the physician will evaluate and document the progress of wound healing especially for those with complicated, extensive, or poorly killing wounds. 2) The interdisciplinary team will update the care plan as appropriate.

Based on observation, interview, and record review, the facility failed to consult with the resident's physician, or the resident's representatives regarding a change in condition for 1 (Resident #1) of 3 residents reviewed for notification of changes. The facility did not consult with Resident #1's Physician or Resident Representative regarding a pressure ulcer that was identified on 03/04/2024 and re-assessed on 04/07/2024. This failure could place residents who presented with pressure ulcers at risk for not receiving appropriate care and interventions. Findings were: Record review of Resident #1's admission record revealed she was [AGE] years old. She was admitted to the facility on [DATE] with a primary diagnosis of dementia with other behavioral disturbances (loss of memory, language, problem solving and other thinking abilities that occurs with agitation and aggressive behaviors), senile degeneration of the brain (mental deterioration), bipolar (mood swings ranging from depressive lows to manic highs), Post-traumatic stress disorder (disorder that results in the person having difficulty recovering after experiencing or witnessing an event), and anxiety (feeling of fear, dread and uneasiness). Record review of Residents #1's Significant Change MDS dated [DATE], revealed the following: -Section C (Cognitive Patterns) reflected a BIMS (Brief interview of Mental Status) score of 07, which was indictive of severe cognitive impairment. -Section M (Skin Conditions) The resident was a high risk for developing a pressure injury but did not have a pressure injury. Record review revealed Resident #1's care plan dated 02/02/2024 revealed the following: -Pressure Ulcer/Injury- Resident was at risk for skin breakdown related to incontinence and thin fragile skin. Goal- Prevent/heal pressure sores and skin breakdown. Approach- Follow facility skin care protocol, preventative measures: area blank, report to charge nurse any redness or skin breakdown immediately and turn while repositing per resident request. -Cognitive loss/dementia- Resident has dementia. Goal- Resident will be alert and oriented as possible. Approach- Anticipate needs and observe for non-verbal cues, approach in a calm manner, explain what you intend to do while providing care, introduce yourself and orient to person, place, and time. -Delirium- Resident has difficulty focusing, easily distracted, and has disorganized thinking. Goal- Resident will be as alert and oriented as possible. Approach- Assess for pain, minimize distraction, and orient PRN. Record review of Resident #1's Weekly skin assessments indicated on: 03/04/2024 - The right heel was a 6 cm x 6 cm, stage 1, no exudate amount, and the tissue were closed and resurfaced. Assessment was completed by LVN #1. 04/07/2024- The right heel was a 1.4 cm x 1.7 cm, unstageable, moderate bloody amount of exudate and the tissue was granulated, with 95% granulated and 5% slough. Assessment was completed by LVN #1. Record review of Resident #1's Nursing Documentation from 02/01/2024 to 04/08/2024 revealed 04/08/2024 at 9:49 PM., by LVN #1, resident was assessed in house by Hospice RN. Received the following wound care orders: Right Heel. cleanse with wound cleanser then pat dry with gauze. Apply hydrogel to wound bed. cover with hydro cellular foam dressing. change daily and PRN. No documentation of Physician, Resident Representative or Hospice Services notification of pressure injury identification or decline prior to this date. During an observation and interview on 04/08/2024 at 11:00 AM., the ADON uncovered Resident #1's right foot bandage and completed a skin assessment on the resident. She revealed that she reviewed the resident's chart and that there showed to be no ongoing skin integrity issues on the resident's right foot, as well as orders or treatments. She measured the right foot and reported that the foot had a 5cm x 5cm unstageable ulcer on it. There was a large ring around wound that had dry white pealing skin, small amount of eschar (black tissue) around some edges of the dry peeling skin. In the central portion of the right heal wound was a smaller open area with red beefy appearance and small amount of yellow tissue. Resident had yellow staining on foot that extended through the arch of her foot. She guessed it was unstageable since there was eschar on the border of the heel wound. She said that this was the first time she was made aware that the resident had any pressure related injuries on her right foot and that if she had been made aware, she would have made sure it was assessed weekly, orders were entered, and treatments were completed daily. She stated that she was responsible for the skin care assessments and the weekly observations were missed because she had not checked to see if they were completed by the nurse's that worked the floor. She stated that this task had been delegated to her by the DON since she started in 2023. She stated that Resident #1 should have had orders entered on 03/04/2024 and that the DON, physician, family, and hospice provider should have been notified. She revealed that she was not aware that an initial observation of the wound was documented on 03/04/3024 or that a subsequent observation was completed on 04/07/2024. She performed Resident #1's wound care by cleaning the area and patting it dry, she then covered the area with the bandage and said that she was going to notify the physician and hospice immediately. During an interview on 04/08/2024 at 11:45 AM., the Medical Director revealed that he saw the resident over the weekend when he was completing his rounds and that he did not document the wound or observe the wound, since he was not made aware that the resident had a wound on her right foot. He stated that his expectations were to be notified anytime there was a change in condition, or for another physician to be notified, as well as hospice and the family. He stated that orders and treatment should have been completed and conducted since it was identified on 03/04/2024. He stated that Resident #1 was frequently confused. He stated that this failure could result in the pressure injury worsening from lack of treatment. During an interview on 04/08/2024 at 1:30 PM., RN#1 (hospice nurse for Resident #1) revealed that they did not have anything in their records that reflected any type of skin integrity issues or pressure ulcers on foot. She reported that there was no documentation in their records that revealed a call from the facility to let them know that a wound had been identified until that date. She reported that she was going to send an RN out to the facility to access wounds and obtained orders and treatments. During an interview on 04/08/2024 at 1:45 PM., with Resident #1's representative revealed that that she was not notified in March 2024 or up to this date in April 2024, that the resident had a pressure ulcer on her right foot. During an interview on 04/08/2024 at 1:50 PM., Resident #1's second representative revealed that he was not notified in March 2024 or April 2024, that the resident had a pressure ulcer on her right foot. During an interview on 04/10/2024 at 2:30 PM., LVN #1, she stated that she was the one who initially identified the wound on her right heel, and she told the nurse who was taking over that day. She revealed that she did not tell the DON, call the Physician, call the family, call the ADON, or call the hospice agency. She stated that even thought she had not notified the physician or hospice to obtain orders, she was cleaning it thoroughly and provided dressing changes when she worked. She stated that she had not completed items because she got busy. She revealed that this failure could result in her pressure ulcers getting worse. A policy titled Change in a Resident's Condition or Status revised on 04/20/2023, revealed the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician, healthcare provider and the resident's representative of changes in the resident's medical mental condition and or status. Policy interpretation and implementation: 1) The nurse will notify the resident's attending physician, health care provider or physician on call when there has been an: d. significant change in the residence physical, emotional, mental condition. e. Need to alter the residence medical treatment significantly. 2) a significant change of condition is a major decline and improvement in the resident status that: a. will not normally resolve itself without intervention by staff or by implementing standard disease related clinical interventions. b. Impacts more than one area of the resident's health status. c. Requires interdisciplinary review and or revisions to the care plan. 3) The nurse will notify the resident's representative when: b. there is a significant change in the residence physical, mental, or psychosocial status.

Based on observation, record review and interview, the facility failed to maintain wound care records on each resident that are accurately documented for 1 of 3 residents (Resident #1) reviewed for records. The facility failed to document that Resident #1 had wound care. This failure to maintain accurate records could affect Residents by receiving inadequate care and services. Findings include: Record review of Resident #1's admission record revealed she was [AGE] years old. She was admitted to the facility on [DATE] with a primary diagnosis of dementia with other behavioral disturbances (loss of memory, language, problem solving and other thinking abilities that occurs with agitation and aggressive behaviors), senile degeneration of the brain (mental deterioration), bipolar (mood swings ranging from depressive lows to manic highs), Post-traumatic stress disorder (disorder that results in the person having difficulty recovering after experiencing or witnessing an event), and anxiety (feeling of fear, dread and uneasiness). Record review on 04/08/2024 at 9:40 AM revealed that Resident #1's care plan dated 02/02/2024 revealed the following: -Pressure Ulcer/Injury- Resident is at risk for skin breakdown related to incontinence and thin fragile skin. Goal- Prevent/heal pressure sores and skin breakdown. Approach- Follow facility skin care protocol, preventative measures: area blank, report to charge nurse any redness or skin breakdown immediately and turn while repositing per resident request. Record review on 04/08/2024 at 9:50 AM revealed that Residents #1's Significant Change MDS dated [DATE] revealed the following: -(Cognitive Patterns) reflected a BIMS (Brief interview of Mental Status) score of 07, which is indictive of severe cognitive impairment. -(Skin Conditions) The resident was a high risk for developing a pressure injury but did not have a pressure injury. Record review of Resident #1's Weekly skin assessments indicated on: 03/04/2024 - The right heel was a 6 cm x 6 cm, stage 1, no exudate amount and the tissue were closed and resurfaced. Assessment was completed by LVN #1. 04/07/2024- The right heel was a 1.4 cm x1.7 cm, unstageable, moderate bloody amount of exudate and the tissue was granulated, with 95% granulated and 5% slough. Assessment was completed by LVN #1. Record review of Resident #1's Nursing Documentation from 02/01/2024 to 04/08/2024 revealed the only documented wound care was on 04/08/2024 at 9:49 PM., by LVN #1, when the resident was assessed in house by Hospice RN. Wound care orders were provided at that time No documentation of wound care orders or treatments provided to right heel prior to this date. Record review of Resident #1's Physician Orders dated 04/08/2024 revealed 04/08/2024 at 11:27 AM revealed the following: call placed to hospice. informed need order for wound to right foot. new order received clean with NS, pat dry cover with foam dressing may wrap with gauze if need for comfort. Hospice stated new orders will be given when res is seen by hospice nurse this week, signed ADON. No orders for wound care prior to this date regarding Resident #1's pressure injury to right foot. During an observation and interview on 04/08/2024 at 10:00 AM., Resident #1 had a gauze wrap around the foot. There was no time, date or initials anywhere on the outside of it. She said that it had been cleaned yesterday by LVN #1, but that was the first time she had cleaned her wound. She said that she has been cleaning it and rewrapping it herself. During an observation and interview on 04/08/2024 at 11:00 AM., the ADON uncovered Resident #1's right foot bandage and completed a skin assessment on the resident. She revealed that she reviewed the resident's chart and that there showed to be no ongoing skin integrity issues on the resident's right foot, as well as orders or treatments. She was unsure why the foot was even bandaged without orders and who bandaged it. During an interview on 04/08/2024 at 11:45 AM., the Medical Director revealed orders and treatment should have been completed and conducted since it was identified on 03/04/2024. During an interview on 04/08/2024 at 1:20 PM., Resident #2 revealed she had seen a nurse provide care for Resident #1's foot a few times, but she did not know her name. During an interview on 04/10/2024 at 2:30 PM., LVN #1, revealed that she remembered that she has been providing wound care. She stated there were no orders for wound care, so she just guessed and did what she thought it needed. She revealed that this failure could result in resident's care areas getting worse. Record review of the Facilities Policy and Procedure titled: Guidelines for Charting and Documentation dated April 2012 revealed the following: The purpose of charting A documentation is to provide: 1) a complete account of the resident's care, treatment, responses to the care, signs, symptoms, etcetera., and the progress of the resident's care. 3) The facility, as well as other interested parties, with the tool for measuring the quality of care provided to the resident. Treatment Orders: Specify what is to be done, location and frequency, and duration of the treatment.

Based on interviews, and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 2 residents (Resident #1) whose records were reviewed for assessments. The facility failed to recognize and re-assess Resident #1 after a pressure ulcer was identified, a fall with major injury occurred and aggressive behaviors presented. This failure placed residents at risk for not developing interventions to meet their needs for care assistance and treatments. Findings include: Record review of Resident #1's admission record revealed she was [AGE] years old. She was admitted to the facility on [DATE] with a primary diagnosis of dementia with other behavioral disturbances (loss of memory, language, problem solving and other thinking abilities that occurs with agitation and aggressive behaviors), senile degeneration of the brain (mental deterioration), bipolar (mood swings ranging from depressive lows to manic highs), Post-traumatic stress disorder (disorder that results in the person having difficulty recovering after experiencing or witnessing an event), and anxiety (feeling of fear, dread and uneasiness). Record review of Resident #1's progress notes revealed the following: -On 02/01/2024 at 6:22 AM., LVN #1 documented that she was alerted to resident by sound of her voice calling out for help. upon entering room observed resident lying face down on the floor mat beside her bed. Resident's speech was slurred and there was a moderate amount of bleeding from the right side of her head. it appears resident's head hit the bed railing when she fell . assessed for any further injury @ that time. - On 02/01/2023 at 3:33 PM., the DON documented that Resident was transported to the Hospital for further evaluation and treatment. Resident received treatment and returned to the facility the same day with 5 staples to frontal area. - On 02/22/2024 at 1:27 PM., RN #2 documented that 5-staples removed from wound on right side of forehead. - On 03/12/2024 at 3:00 PM., DON documented that she was notified that this resident engaged in a physical altercation with another resident on the west hall near the nurse's station. Per witnesses in area, this resident was yelling at other residents to shut up when they responded this resident became upset and struck a fell ow resident on their neck giving them an abrasion. That resident retaliated with a return physical strike causing this resident to have a skin tear to the left side of her neck. Residents were immediately separated by staff and kept separated. - On 03/14/2024 at 9:24 AM., The SW documented he was informed that Resident #1 had been involved in an altercation where she struck another resident. - On 03/28/2024 at 3:52 PM., ADON documented that new order received from NP with psych services, Seroquel 25mg po q day prn x 14 days (1 extras dose during the day if needed daily in addition to scheduled nightly dose. Record review of Resident #1's Significant Change MDS dated [DATE] revealed the following: -Section C (Cognitive Patterns) reflected a BIMS (Brief interview of Mental Status) score of 07, which is indictive of severe cognitive impairment. Disorganized Thinking - The behavior is present and fluctuates, the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. -Section E (Behavior) reflected that: Resident #1 did not have behaviors that put them at significant risk for physical illness or injury. -Section J (Health Conditions- Falls) reflected that the resident did not have a fall with Major injury - bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma. -Section M (Skin Conditions) reflected that resident did not have a pressure injury or skin injury. Record review of Resident #1's Weekly skin assessments indicated on: 03/04/2024 - The right heel was a 6 cm x 6 cm, stage 1, no exudate amount, and the tissue were closed and resurfaced. Assessment was completed by LVN #1. 04/07/2024- The right heel was a 1.4 cm x1.7 cm, unstageable, moderate bloody amount of exudate and the tissue was granulated, with 95% granulated and 5% slough. Assessment was completed by LVN #1. In an interview on 04/09/2024 at 2:00 PM., the DON revealed that the resident did have a change of condition from her last MDS, with additional areas that should have been identified and addressed with a new comprehensive assessment. In an interview on 04/10/2024 at 3:00 PM, the MDS coordinator revealed the resident had a pressure ulcer that was identified on March 04, 2024 , decline in behaviors, and a fall with major injury occurred. She revealed that resident had a significant change since the last MDS in February due to the resident's aggression, falls and pressure ulcer. She revealed that this failure could cause the resident to miss care areas such as the wound care that was not care planned or completed and other care areas that were not being identified and/or a comprehensive care plan being completed. Record review of the facility's policy covering MDS inaccuracies was requested to the MDS coordinator on 04/10/2024. She revealed that she uses the RAI manual for guidance.

Based on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 3 residents (Resident #1) whose records were reviewed for assessments and care plans, as well as having an IDT team present at the care conference. The facility failed to ensure that Resident #1 had an Intradisciplinary Team care conference after Residents #1's Significant Change MDS dated [DATE]. This failure could place residents at risk of not have having their care plans completed accurately and timely. Findings included: Record review of Resident #1's admission record revealed she was [AGE] years old. She was admitted to the facility on [DATE] with a primary diagnosis of dementia with other behavioral disturbances (loss of memory, language, problem solving and other thinking abilities that occurs with agitation and aggressive behaviors), senile degeneration of the brain (mental deterioration), bipolar (mood swings ranging from depressive lows to manic highs), Post-traumatic stress disorder (disorder that results in the person having difficulty recovering after experiencing or witnessing an event), and anxiety (feeling of fear, dread and uneasiness). Record review of Residents #1's Significant Change MDS dated [DATE] revealed the following: -Section C (Cognitive Patterns) reflected a BIMS (Brief interview of Mental Status) score of 07, which is indictive of severe cognitive impairment. Disorganized Thinking - The behavior is present and fluctuates, the resident's thinking disorganized or incoherent (rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject. -Section J (Health Conditions- Falls) reflected that the resident did not have a fall with Major injury - bone -Section M (Skin Conditions) The resident was a high risk for developing a pressure injury but did not have a pressure injury. Record review of Resident #1's electronic Care Conference record did not have an IDT care plan after the Significant Change MDS on 02/01/2024. In an interview on 04/08/2024 at 1:45 PM., with Resident #1's representative revealed she was not invited to a care plan in a while, it has been at least since 2023. The family would like to attend by phone and be involved in the care plan process and resident care areas. In an interview on 04/09/2024 at 2:00 PM, the DON revealed that she was not responsible for the care plans, the MDS was after completion of the MDS assessment. She revealed even though the care plan meetings were not completed timely By the IDT, she still ensured residents received the care and there were no issues with quality of care. In an interview on 04/10/2024 at 1:00 PM., the SW revealed that he was not aware the Resident #1 had a Comprehensive MDS completed in February. He stated he was responsible for scheduling the care conference and he did not schedule one. He revealed the last one was completed was on 08/30/2023. He stated it was missed and he was just capturing the Quarterly and Annual assessments that he was notified of. He revealed he was never notified of the resident having a Significant Change. He revealed this failure could cause a care conference not being completed. In an interview on 04/10/2024 at 3:00 PM, the MDS coordinator revealed that she was unsure how why the IDT meeting got missed. She said this failure would place the residents at risk for inaccurate care plans and assessments which could cause a quality-of-care issue. She revealed that even though the care plans were not completed correctly, they still took care of the residents. Record review of the facility's policy titled: Care Plan, Comprehensive Person-Centered dated January 26, 2024, revealed the following: 5) The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MSDS assessment.

Based on observations, interviews, and record reviews, 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 for 1(Resident #1) of 2 residents reviewed for infection control practice. CNA (Certified Nurse Assistant) A failed to perform hand hygiene and change her gloves at the appropriate times while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection. Findings included: Review of Resident #1's face sheet, dated 02/21/24, revealed the resident was a 61- year- old female admitted to the facility on [DATE] with diagnoses of personal history of Covid-19, urinary tract infection, viral disease, candidiasis (fungal infection), streptococcal infection (bacterial infection), and constipation. Review of Resident #1's MDS assessment, dated 12/27/23, revealed Resident #1 has a brief interview for mental status (BIMS) of 13 indicating cognitively intact. Resident required extensive assistance with most ADL s and one person assist. Resident #1 was always incontinent of bowel and bladder. Review of Resident #1's care plan dated 03/28/24, revealed the resident was care planned for urinary incontinence but not for bladder incontinence. Observation of incontinence care for Resident #1 on 02/20/2 at 11:02a.m. revealed CNA A did not wash her hands but put on gloves before commencing care. She wiped the resident from front to back. Resident #1 brief was soiled with urine and fecal matter. CNA A gloves were visibly soiled but she continued to use it to clean the resident. CNA A did not wash hands, change gloves, or perform hand hygiene but proceeded to retrieve Resident#1's clean brief. She placed the clean brief on the resident and fastened it. CNA A removed her gloves, picked up the trash and walked out of the room without washing hands or performing hand hygiene. Interview with CNA A on 02/20/24 at 11:12 a.m. revealed she had been employed at the facility for about 1 year and received infection control training 2 weeks ago. She stated cross contamination was mixing clean with dirty. CNA A stated she should have washed hands before starting and after providing care. She added that Resident #1 could get infection for not using good hand hygiene. During an interview with the DON on 02/21/24 at 11:23a.m she acknowledged she was aware of some of the concerns raised about infection control. She said she expected her staffs to gather supplies, wash hands and donned gloves before and after providing care. The DON stated she was responsible for infection control in the facility. She explained the facility conducts infection control training with return demonstration quarterly. She noted the ADON does surprise checks on staffs to ensure they are following good infection control practice. Review of the facility handwashing/hand hygiene policy revised 01/20/23 reflected, This facility considers hand hygiene the primary means to prevent the spread of infections. Policy interpretation and implementation: 1) All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 2) Residents, family members and/or visitors will be encouraged to practice hand hygiene throughout the facility. 3) Wash hands with soap and water, when hands are visibly soiled and after contact with resident with infectious diagnosis .

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #13) whose records were reviewed for quality of care. 1. The facility failed to ensure a physician-ordered wander guard was in place for Resident #13. 2. The facility failed to prevent Resident #13 from leaving the facility unaccompanied on 10/05/23. This failure resulted in Immediate Jeopardy on 9/30/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 9/30/23 at 6:37 PM and ended on 10/06/23. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance into the facility on [DATE]. The facility's failure placed residents at risk for harm and injury from an incident of elopement. The findings included: Review of Resident #13's Face Sheet, not dated, revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included: dementia with other behavioral disturbance; other depressive episodes; restlessness and agitation; anxiety disorder; schizoaffective disorder (mental disorder with abnormal thought processes with symptoms of schizophrenia characterized by psychosis and bipolar disorder characterized by mood swings ranging from high to low). Review of Resident #13's Significant Change in Condition MDS Assessment, dated 9/27/23 revealed the resident was assessed as having a BIMS score of 1 out of 15 (severe cognitive impairment); verbal behavioral symptoms 1-3 days during the past 7-day review period; and wandering behavior 1-3 days during the past 7-day review period. Review of Resident #13's comprehensive care plan, dated as initiated 6/24/22 revealed it addressed the resident's risk for elopement. A documented intervention was added 9/28/23 for wander guard in place to be checked every shift. Review of Resident #13's Physician orders revealed the following: 6/24/22 - Wander Guard: Check placement every shift to left leg. 3/29/23 - Wander Guard: Apply to Resident for safety related to wandering and/or elopement seeking. Change bracelet per manufacturer's guidelines. Review of Resident #13's Quarterly Elopement evaluation, dated 7/31/23, revealed documentation the resident was ambulatory, cognitively impaired, had a history of wandering, and an elopement care plan was initiated. Review of the Nursing Progress Note, dated 9/30/23 at 11:03 AM, revealed Resident #13 sat down by the nurse's cart, stated she could not breathe, and grabbed her chest. The nurse assessed her oxygen saturation level to be at 60% and an oxygen mask was applied. The resident's vital signs were taken with a blood pressure noted at 88/49 and a heart rate of 124. A call was made to 911 for an ambulance and Resident #13 was transported via ambulance to the hospital emergency room . Resident #13's family member was notified. Review of the Nursing Progress Note, dated 9/30/23 at 6:37 PM, revealed Resident #13 returned to the facility via ambulance and was taken via stretcher to her room and placed in bed. No new orders were received. The resident ate the evening meal in the dining room and consumed 100% of the meal. No discomfort was noted. Vital signs were within normal limits and the resident continued to be monitored closely. Review of the Nursing Progress Note, dated 10/05/23 at 9:11 AM, revealed Dietary Aide A called LVN C and told her Resident #13 was down the street. The nurse documented she went outside and the resident was in the street. The dietary aide assisted Resident #13 into his car and brought her to the facility. Resident #13 walked into the facility with LVN C. The nurse documented the resident was assessed from head to toe and no open areas or bruises were noted. A wander guard was applied to her right wrist. The resident denied feeling any pain. Review of the Social Services Progress Note, dated 10/05/23 at 4:24 PM, revealed Resident #13's family member was notified regarding the resident being identified walking about a block from the facility. The note documented the family member asked what had occurred and she was informed the wander guard had been removed when Resident #13 went to the hospital. The family member was informed that all doors leading to the outside had been checked to ensure the locking mechanism worked correctly and a wander guard had been placed on Resident #13 to prevent any future elopement. Review of Resident 13's Medication Administration Records, dated October 2023, revealed they included a visual check of the resident every 2 hours related to wandering and/or exit seeking. The times listed were 12:00 AM, 2:00 AM, 4:00 AM, 6:00 AM, 8:00 AM, 10:00 AM, 12:00 PM, 2:00 PM, 4:00 PM, 6:00 PM, 8:00 PM, and 10:00 PM. Each time frame was initialed by the nurse on duty. Review of the Incident Investigation Summary report, dated 10/05/23, revealed Resident #13 did not have a wander guard on at the time of the incident, due to the wander guard being removed prior to being sent to the hospital. The wander guard was not replaced upon her return to the facility and the wander guard checks had not been done. The report documented the incident was reported to the State agency on 10/05/2023 at 12:22 PM. The report documented a staff in-service training was conducted to reiterate that wander guard checks needed to be performed, and the facility's policies for Missing Resident and Wandering and Elopements were reviewed with the staff. The report documented the wander guard was in place and was being checked multiple times daily and an alternate placement was being sought for Resident #13 (in a facility with a secured unit). Review of the Event Report for Elopement, dated 10/05/23, revealed Resident #13 was found off the property on the street. The resident was assessed with no injuries sustained. The resident wandered with no rational purpose and attempted to open doors, and elopement attempts in the past had been unsuccessful. Resident #13 had dementia. The immediate intervention of a door alarm wander guard band was applied and the band was effective and started alerting when the resident went near a door to the outside. The report evaluation notes revealed the wander guard was in place and checked multiple times daily and an attempt was being made to find an alternate placement. Observation on 10/12/23 at 10:54 AM revealed Resident #13 was ambulating in the [NAME] Hall and walked to the end of the hallway and looked out the glass window to the right side of the exit door. She was not wearing shoes. A wander guard security band was on her right wrist. In an interview on 10/10/23 at 1:59 PM, the Administrator revealed Resident #13 had been sent to the emergency room after being agitated and falling. She was brought back to the facility. The Administrator stated Resident #13's wander guard band was cut off from her ankle before she was transferred to the hospital, because the wander guards were lost when residents were at the hospital. Another wander guard band was not applied following her return from the hospital. The Administrator stated about one week after her return, Resident #13 eloped from the facility and was seen at a street corner intersection by a dietary aide . She stated he was in his car and Resident #13 got in the car and was brought back. The Administrator stated it was unknown how Resident #13 left the building. She stated the resident was not observed exiting, but a door must have been left ajar. Resident #13 left during the mid-morning. She was assessed by the ADON and no injury was noted. The Administrator stated Resident #13 had dementia and was not oriented at all. The Administrator stated, She likes to walk. In an interview on 10/13/23 at 12:53 PM, LVN C, the [NAME] Hall charge nurse, stated she was on duty the morning of 10/05/23 when Resident #13 left the facility unattended. She stated it was during the morning medication pass between 8:30 AM and 9:30 AM. LVN C stated her brother (Dietary Aide A) worked in the facility kitchen and worked a split shift. She stated Dietary Aide A had just clocked out and left after the breakfast meal service, and he called her and told her Resident #13 was outside on the street. He was able to get her into his car and brought her back. LVN C stated she was waiting and met Resident #13 and Dietary Aide A outside in front of the building and assisted the resident back into the building. She stated Resident #13 was wearing socks, but no shoes. LVN C stated she did a head-to-toe assessment on Resident #13 and did not find any evidence of injury. She stated the resident had not fallen outside. LVN C stated Resident #13 did not have a wander guard security band on at that time, and one was applied to her wrist that day. LVN C stated no one saw Resident #13 leave the building. She stated the resident may have followed someone out the door. LVN C stated Resident #13 could move pretty fast. LVN C stated Resident #13 had not had any prior incidents of elopement or leaving the facility unattended prior to the incident on the morning of 10/05/23. In an interview on 10/13/23 at 1:10 PM, the DON stated the staff were having the morning meeting when Resident #13 left the faciity on [DATE]. She stated no one saw her leave the facility. During an interview and observation on 10/13/23 at 3:25 PM, the Maintenance Director stated he thought he knew which door Resident #13 left from on 10/05/23. He led the way to the East Hall sunroom door that led to the patio at the front end of the building. There was a sign on fluorescent green laminated paper on the inside of the door leading to the patio: For the safety of our Wandering Residents please ensure the door closes completely. The Maintenance Director stated the sign was already posted on the door when he started working in the facility one year ago. He stated the door was locked and the lock was released using the keypad code on the wall to the side of the door. He stated the door had a self-closure device and the door would close and latch when opened wide enough to reach the catch point where the door was pulled back to the frame and closed securely, latched and locked. The Maintenance Director demonstrated the opening of the door and stated if the door was only opened a foot for someone to slide out, the door did not pull back tightly and close securely and latch. He stated Resident #13 wandered and checked all the doors. He stated she probably saw the door was open about an inch and pushed it open and left. He stated residents seated in the front lobby entrance reportedly saw her walking outside the front of the building. Resident #13 was brought back into the facility by the charge nurse. He stated the staff morning meeting was held in the conference room and staff may not have noticed Resident #13 walking outside. In an interview on 10/13/23 at 4:35 PM, Dietary Aide A stated he was leaving the facility following the breakfast meal service on Thursday 10/05/23. He stated when he pulled his car onto the street he saw a lady walking on the street. He stated he thought it looked like Resident #13, so he drove around the block and came back. He stated it was Resident #13, so he stopped the car and called LVN C. He stated she came out of the building and told him to get Resident #13 into his car and bring her back. Dietary Aide A stated he talked with Resident #13, she got in the car, and he brought her back. He stated LVN C was waiting outside the front of the building and helped bring Resident #13 back inside. He stated Resident #13 was wearing socks but no shoes. He stated she did not fall. Telephone interview with Resident #13's family member on 10/27/23 at 3:13 PM revealed the resident had not had any prior incidents of elopement from the facility since her admission to the facility during December 2020. The incident on 10/05/23 had been the resident's first time to leave the facility unattended. Review of the facility's policy and procedure for Wandering and Elopements, dated as revised 9/01/2023, revealed the following [in part]: Policy Statement The facility will ensure that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care. Immediate Jeopardy at Past Non-compliance was called on 10/27/23 at 7:41 PM and the Administrator was provided the IJ Template. The facility completed the following corrective actions to address the non-compliance after the incident occurred and prior to the surveyors entering the facility: Review of the staff in-service attendance record, dated 10/06/23, revealed the Administrator provided an in-service lecture regarding wander guards and the facility policy for Wandering and Elopements. The time of the inservice was not documented on the attendance record. Review of the facility Wander Guard binder notebook revealed information regarding the scanning device used to check the wander guard band for function. The book included a copy of Resident #13's Face Sheet, a Wander Risk Information form with Resident #13's picture, and the Consent for Use of Wander Guard form signed by her family member on 12/11/2020. Resident #13 was the only resident identified by the facility as being at risk for wandering and had information in the Wander Guard binder notebook. Review of Resident #13's Medication Administration Record, dated October 2023, revealed a Wander Guard Function Test was to be completed one time daily on the 6 AM - 2 PM shift and was initialed by the day shift nurses as being completed 10/05/23 - 10/27/23. Review of the Maintenance Director's weekly Logbook Documentation forms for October 2023 revealed test operation of doors and locks were completed daily Monday through Friday for the east doors, front entrance door, and west doors and pass was documented for each date. He provided the completed weekly logs dated from October 2022 to the present. Observations of Resident #13 on 10/26/23 at 4:33 PM while in bed and on 10/27/23 at 12:36 PM while walking in the middle hallway near the dining room revealed the wander guard security band was in place on her right wrist. Observations of all the facility doors were conducted during a round with the facility Maintenance Director on 10/26/23 between 4:16 PM and 4:50 PM. All hall exit doors alarmed and released within 15 seconds. The front door was the only door with an alarm that would activate by a wander guard security band. All doors were securely closed and locked. Interviews with the LVN charge nurse, the medication aide, and the certified nurse aide working on Resident #13's hall, who were on duty for the evening shift on 10/26/23 revealed visual checks of the resident were conducted every 2 hours. The LVN and medication aide stated the resident's wander guard band was tested for proper functioning one time daily on another shift and was documented on the medication administration record by the nurse conducting the test. The Corporate RN Clinical Resource Nurse was observed using the scanning device to check the function of Resident #13's wander guard on 10/27/23 and the resident's wander guard was functioning properly. Interview with a certified nurse aide during the day shift on 10/27/23 revealed the Administrator had given a staff in-service training on 10/06/23 and had talked about wander guards, wandering, and visual checks of Resident #13. The certified nurse aide stated the Administrator told the staff not to use the east hall door located in the front part of the building (sunroom). Interview with the Maintenance Director on 10/27/23 revealed he checked the self-closing device and adjusted it as needed for the east hall door leading from the sunroom at the front of the building. He stated he had adjusted the self-closing device several times before Resident #13's elopement from the facility. He said he checked it and adjusted it first thing after Resident #13's elopement and return to the facility on [DATE]. He was observed adjusting the self-closure device on the east hall door in the sunroom and opening the door to test the door closure on 10/27/23 at 1:53 PM. This failure resulted in Immediate Jeopardy on 9/30/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 9/30/23 at 6:37 PM and ended on 10/06/23 following a staff inservice training provided by the Administrator. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance to the facility on [DATE].

Based on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days per week for 2 of 3 months (April 2023 and May 2023) reviewed for RN coverage, in that: The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 8 of 61 days during April 2023 and May 2023. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff. The findings included: Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 3, 2023 (April 1, 2023-June 30, 2023), run date 10/05/2023, revealed no evidence of RN coverage for 8 of 61 days during April 2023 and May 2023: 1. 04/01/2023 with no RN coverage; 2. 04/02/2023 with no RN coverage; 3. 04/15/2023 with no RN coverage; 4. 04/16/2023 with no RN coverage; 5. 04/29/2023 with no RN coverage; 6. 04/30/2023 with no RN coverage; 7. 05/06/2023 with no RN coverage; 8. 05/07/2023 with no RN coverage. In an interview on 10/12/2023 at 04:44 PM, the DON and Corporate Clinical Resource Nurse said there was not coverage for those dates. The DON said possible negative outcomes of not having RN coverage was certain assessments that RNs can only do would not get completed. They denied knowledge of any negative outcomes for the reported period of no RN coverage. A facility policy was requested on 10/12/2023 at 04:44 PM, but the facility failed to provide evidence of policies or procedures regarding utilization of RNs for 8 consecutive hours a day for 7 days per week.

Based on observation and interviews the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 6 residents (Resident #28) whose room was observed for cleanliness, in that: Resident #28 had feces on his bed linens for 2 days. This facility failure placed residents at risk for decreased feelings of well-being and sense of self-worth within their living environment. The findings included: Record review of Resident #28's face sheet, dated 10/28/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE] with a latest return on 01/25/2023. Diagnoses included acute on chronic diastolic congestive heart failure (impairment of the heart's blood pumping function) and constipation (a bowel dysfunction that makes bowel movements infrequent or hard to pass). Record review of Resident #28's Quarterly MDS Assessment, dated 07/12/2023, revealed the resident had a BIMS score of 10 out of 15 (moderate cognitive impairment). In an observation and interview on 10/11/2023 at 01:37 PM, Resident #28 had an approximate area of 5 inches by 5 inches of feces on the sheets on his bed. He stated he had received an enema earlier that day and feces got on the bed. In an observation and interview on 10/12/2023 at 01:47 PM, Resident #28's bed linens still had feces on them from the day before. Resident #28 said he had asked the staff to change his sheets yesterday, but they never did. He said he had asked again this morning for his sheets to be changed but it had not been done yet. He said that when he had his enema yesterday, feces got on his sheets. He said, I couldn't help it. In an interview on 10/13/23 at 2:57 PM, LVN H stated if a nurse performed an enema and feces got on the bed, the nurse should clean it up. The LVN stated if a CNA went into the room and noticed feces on the bed, they should clean it up. In an interview on 10/13/23 at 2:05 PM, the ADON stated when a staff member saw a mess they should clean it up, or if they were not able they should notify someone. In an interview with the DON and the Corporate Clinical Resource Nurse on 10/13/23 at 2:10 PM, the DON said she gave Resident #28 an enema and she did not notice any feces on his bed after the procedure. The Corporate Clinical Resource Nurse said anyone that saw a mess should clean it up. She said the nurses when they made rounds or the CNAs when they went into the room should have cleaned it up. Record review of the facility policy Homelike Environment, dated as revised February 2021, revealed the following [in part]: Policy Statement: Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation: 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment; e. clean bed and bath linens that are in good condition.