Every finding on record at Avir at Jefferson

Based on interviews and record review, the facility failed to notify the resident's representative and physician when there were changes in the resident's physical, mental, or psychosocial status for 1 of 9 residents (Resident #2) reviewed for notification of changes.The facility failed to notify MD E of Resident #2 refusing meals and eating poorly during the month of 2/2026.The facility failed to notify MD E of Resident #2 being combative and refusing medications on 2/15/26.The facility failed to notify Resident #2's RP of his poor oral intake and refusing to eat the month of 2/2026.The facility failed to notify Resident #2's RP of him being combative and refusing his medications on 2/15/26.These failures could place residents at risk of not receiving adequate and timely interventions and a decline in condition. Findings included:Record review of Resident #2's face sheet dated 2/20/26 indicated he was [AGE] years old and admitted to the facility on [DATE] initially and re-admitted on [DATE]. Resident #2 had diagnoses including cerebral infarction, dysphagia (difficulty swallowing), cerebrovascular disease, chronic kidney disease, blindness right eye, vascular dementia (progressive decline in thinking skills caused by reduced flood flow to the brain), malignant neoplasm of the brain (mass that invades the surrounding brain tissue), unspecified symptoms and signs involving cognitive functions following cerebral infarction, repeated falls, depression and hypertension.Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he had been admitted from a short-term hospital. The MDS indicated he had a BIMS score of 7, which indicated he had severe cognitive impairment. The MDS indicated Resident #2 used a wheelchair for mobility. The MDS indicated Resident #2 was dependent on staff assistance for all ADLs, including eating. The MDS indicated Resident #2 was always incontinent of bowel and bladder.Record review of Resident #2's Care Plan with an admission date of 12/27/25 revealed the resident had a nutritional problem or potential for nutritional problem with intervention including to monitor/document/report to MD as needed for signs and symptoms of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals.Record review of Resident #2's Order Summary Report dated 2/21/26 revealed an order for may have health shake if resident consumes less than 50 % of meal as needed. Encourage intake of health shake if less that 50 percent of any meal consumed and notify nurse with a start date of 5/08/24.Record review of Resident #2's Nursing Medication Administration Record dated 2/1/26-2/28/26 revealed an order for may have health shake if resident consumes less than 50 % of meal as needed. Encourage intake of health shake if less that 50 percent of any meal consumed and notify nurse. There was no documentation that the resident received a health shake during the time period.Record review of Resident #2's Nutrition-Amount Eaten documentation revealed he consumed on:2/2/26-0-25% for one mealRefused one meal2/3/26-0-25% for one meal26-50% for 2 meals2/4/26-0-25% for one meal26-50% for 2 meals2/6/26-0-25% for two meals2/7/26-0-25% for one mealRefused one meal2/8/26-0-25% for two mealsNo documentation for 3rd meal2/9/26-0-25% for one mealNo documentation for two meals2/10/26-0-25% for one meal26-50% for one mealRefused one meal2/11/26-26-50% for one meal2/12/26Refused two meals2/13/26-0-25% for one meal26-50% for one meal2/14/26-Refused two meals2/15/26-0-25% for two mealsRefused one meals2/16/26-0-25% for one meal26-50% for one mealRefused one mealRecord review of Resident #2's weights indicated he weighed 158.6 pounds on 12/29/25 after discharging from the hospital on [DATE] and weighed 160.6 pounds on his last documented weight on 2/09/26.Record review of Resident #2's Nutritional Risk assessment dated [DATE] indicated his most recent weight was 160.6, he had a BMI of 22 (normal was 19-24.9), no weight changes were noted, his intake varied, and to continue current nutrition plan.Record review of Resident #2's nurses' notes from 2/1/26 through 2/16/26 did not indicate staff had notified the physician or Resident #2's RP related to refusing meals or eating poorly. MA D's note dated 2/15/26 at 7:01 PM indicated Resident #2 was resistant when trying to give medications, started swinging/swatting and Resident #2 was not allowing her to take his blood pressure and was not swallowing anything. There was no documentation MA D notified the nurse of behavior.During an interview on 2/20/26 at 10:53 AM, Resident #2's RP #1 said if he was refusing to eat or take his medication, the staff should have notified his nurse, so the nurse could have notified his physician, and his family, so they could help or intervene prior to him getting to the level he was currently in with dehydration and malnutrition.During an observation on 2/21/26 beginning at 9:30 AM, Resident #2 was observed lying in bed in the hospital. He only nodded that he was doing okay but would not or could not talk with this surveyor. He was noted to have a feeding tube inserted through his nose.During an interview on 2/21/26 at 1:58 PM, Resident #2's RP #2 said no one from the facility had contacted her regarding Resident #2 refusing to take anything by mouth. Resident #2's RP #2 said Resident #2 was in the hospital for severe dehydration, not being fed, and pneumonia. Resident #2's RP #2 said had she known he was refusing to take anything by mouth; she would have come to see him and tried to intervene.During an interview on 2/21/26 at 4:26 PM, LVN B said she had worked at the facility for twelve years. LVN B said Resident #2 was an elderly man, had a tumor in the brain and was progressively going down, and had to be fed. LVN B said no one had reported to her that he was being combative or not taking his medications. LVN B said it should have been reported to her as his nurse. LVN B said she would have reported it to Resident #2's physician and Resident #2's family because it was out of character for Resident #2. LVN B said Resident #2 could have had a urinary tract infection or anything causing the changes. LVN B said she had never known Resident #2 to be combative, and no one had reported it to her. LVN B said there was a possibility if Resident #2 had an infection it could have gotten worse from not notifying the physician. LVN B said Resident #2's family was highly involved in his care and should have definitely been contacted.During an interview on 2/21/26 at 5:46 PM, MA D said she had worked at the facility since 9/2024. MA D said she would try three times if a resident refused their medications, then would tell the nurse to let them try. MA D said Resident #2 would not let her take his blood pressure on 2/15/26 and was swinging at her and she told the nurse, but she did not remember who the nurse was. MA D said she tried to give him his medications on a spoon with some pudding, and she put it in his mouth. MA D said then Resident #2 would not swallow the medication and he would not drink any water with the medication. MA D said she had crushed it in pudding and she ended up spooning it back out of his mouth so he would not choke on it later. MA D said she asked him if he was okay and he kept shaking his head no. MA D said the aide told her that he would not eat or even open his mouth for her. MA D said Resident #2 went from holding his food in his mouth to not even opening his mouth at all. MA D said she went and let the nurse know he would not take his medication. MA D said she normally documented in the note that the nurse was notified, because she does let them know. MA D said Resident #2 had greatly declined after he came back from the hospital the end of December. MA D said it was not normal for him to swing and swat. MA D said she thought his decline in health was part of why he was behaving. MA D said she always tells the nurse if there was anything going on with the residents, but she must have forgotten to document it the day Resident #2 was swinging/swatting and refusing to take his medication.During an interview on 2/22/26 at 1:49 PM, MD E said he had been Resident #2's physician for over twenty years and was also seeing him in the hospital. MD E said he did not remember being told Resident #2 was not eating well. MD E said Resident #2 had a history of significant weight loss and he had put medications in place and added health shakes. MD E said Resident #2 had gained some weight back and then went back into the hospital with the flu and got septic (life threating body's response to infection) and lost weight. MD E said he would have expected to be notified if the resident was not eating well, so he could have put interventions in place. MD E said he was not notified of Resident #2 being combative or refusing his medications on 2/15/26. MD E said the nurse may have been waiting to see if it was a pattern and needed to investigate before notifying him. MD E said if there was an active problem with the resident and staff did not notify him timely, it could delay diagnosis and treatment to some extent. MD E said Resident #2 had a tumor in his brain and it had gotten bigger, along with his age and history of stroke, which were contributing factors of his cognitive decline and did not feel it was related to his care at the facility.During an interview on 2/22/26 at 2:41 PM, the DON said Resident #2 could not feed himself at all. The DON said staff should notify the physician and RP about anything abnormal, such as lab results, changes, adverse reactions, for sure should notify of meal refusals and document it. The DON said the CNA should have notified the nurse if a resident was refusing or not eating well. The DON said the physician should have been notified if the resident was refusing medications. The DON said MA D should have notified LVN B so she could have determined if the physician and the RP needed to be notified. The DON said the physician not being notified of changes, did not allow the physician to intervene and put things in place such as labs or anything. The DON said Resident #2's RP should have be notified to keep them in the loop for that family member of what is going on.During an interview on 2/22/26 at 3:08 PM, the ADM said she had been the ADM for about two and a half weeks. The ADM said the physician should be notified about not eating, not swallowing, or any kind of change of condition. The ADM said she would notify the physician immediately if she knew there was a change in the resident's normal behavior. The ADM said the physician absolutely should have been notified about Resident #2's poor appetite. The ADM said not notifying the physician could have caused the patient to lose weight. The DON said the physician may have wanted to give orders, but we will never know since he was not notified. The ADM said not notifying the physician of a change in condition could delay the resident's treatment. The ADM said she would expect the facility policies to be followed. The ADM said the family should have also been notified with any changes in condition with the resident. The ADM said family should always be notified of any changes with their loved ones so they could be a part of the decision-making process. The ADM said RP/family probably did not know Resident #2 had a change until they got the call he was sent out to the hospital.Record review of the facility's policy titled Change in a Resident's Condition or Status dated revised April 2025, indicated . Our facility promptly notifies the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition and/or status . 1. The nurse will notify the resident's attending physician or on-call physician when there has been . d. a significant change in the resident's physical/emotional/mental condition . f. refusal of treatment or medications three or more consecutive times . 2. A significant change of condition is a major decline or improvement in the resident's 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 revision to the care plan . 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when . b. there is a significant change in the resident's physical, mental, or psychosocial status . 5. Except in medical emergencies, notifications will be made within twenty-four hours of change occurring in the resident's medical/mental condition or status .

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 2 of 9 residents (Resident #1 and Resident #2) reviewed for care plans.1. The facility failed to ensure a care plan was developed and implemented for Resident #1's allergies, discharge plans, code status, cognitive status, incontinence status, activities, pain management, diet, ADL assistance required, risk for falls, risk for pressure ulcers, risk for bleeding, preferences, disease processes: hypertension, hemiplegia and hemiparesis following cerebral infarction, nutritional deficiency, heart disease, or polyneuropathy, and medications: antianxiety, opioid, antiplatelet, anticonvulsant, diuretics and antidepressant.2. The facility failed to update Resident #2's ADL care plan to show he was dependent on staff for eating.3. The facility failed to implement Resident #2's order of: may have health shake if resident consumes less than 50 % of meal as needed. Encourage intake of health shake if less that 50 percent of any meal consumed and notify nurse.This failure could place residents in the facility at an increased risk of a decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed to address their needs. Findings included:1. Record review of Resident #1's face sheet dated 2/20/26 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses including cerebrovascular disease (narrowing, blockage, or rupture of the blood vessels that supply the brain), hemiplegia (unable to move one side of body) and hemiparesis (weakness on one side of body) following cerebral infarction (stroke-death of brain tissue caused by lack of oxygen due blocked blood flow) affecting unspecified side, adult failure to thrive, polyneuropathy (nerve pain), hypertension (high blood pressure), atherosclerotic heart disease (plaque buildup in the blood vessels supplying the heart), and nutritional deficiency.Record review of Resident #1s admission MDS assessment dated [DATE] indicated he had been admitted to the facility on [DATE] from a short-term hospital. The MDS indicated he had a BIMS score of 12, which indicated he had moderate cognitive impairment. The MDS indicated Resident #1 had functional limitation in range of motion with impairment affecting upper and lower extremities on one side. He used a wheelchair for mobility. He required partial to substantial assistance performing most ADLs. The MDS indicated Resident #1 was frequently incontinent of bladder and occasionally incontinent of bowel. The MDS indicated Resident #1 received scheduled pain medication for frequent pain. The MDS indicated he had a history of falls prior to admission. The MDS indicated he had a risk of pressure ulcers. The MDS indicated he received antidepressant (treats depression (persistent sadness), diuretic (reduces excessive fluid in the body), opioid (narcotic-used to manage severe pain), antiplatelet (used to treat heart disease with common risk of bleeding), and anticonvulsant (used to treat seizures, nerve pain, and mood disorders) medications. The MDS was signed as completed on 1/29/26.Record review of Resident #1's undated Care Plan with an admission date of 1/18/26 revealed he only had problem areas related to risk for impaired skin integrity wound and a problem area of the resident had an actual fall. Resident #1's care plan did not include problem areas and interventions related to allergies, discharge plans, code status, cognitive status, incontinence status, activities, pain management, diet, ADL assistance required, risk for falls, risk for pressure ulcers, risk for bleeding and preferences. The care plan did not include problem areas and interventions for disease processes of hypertension, hemiplegia and hemiparesis following cerebral infarction, nutritional deficiency, heart disease, or polyneuropathy. The care plan did not include problem areas and interventions for antianxiety, opioid, antiplatelet, anticonvulsant, diuretics and antidepressant medications.During an observation and interview on 2/21/26 at 4:15 PM, Resident #1 was sitting up in his wheelchair. Resident #1 said he was not able to use his right arm or leg. Resident #1 said he had been a very independent and active man until his recent stroke. Resident #1 said he was continent of urine, but he did need assistance of someone to hold his urinal because he could not navigate getting his pants down far enough, pull his penis out, and hold the urinal all with one hand. He said he did not want to ask for assistance, but he did not want to piss on himself either. Resident #1 said he was mad about his current health situation and his whole life had changed, and he did not feel the facility realized that.2. Record review of Resident #2's face sheet dated 2/20/26 indicated he was [AGE] years old and admitted to the facility on [DATE] initially and re-admitted on [DATE]. Resident #2 had diagnoses including cerebral infarction, dysphagia (difficulty swallowing), cerebrovascular disease, chronic kidney disease, blindness right eye, vascular dementia (progressive decline in thinking skills caused by reduced flood flow to the brain), malignant neoplasm of the brain (mass that invades the surrounding brain tissue), unspecified symptoms and signs involving cognitive functions following cerebral infarction, repeated falls, depression and hypertension.Record review of Resident #2's quarterly MDS assessment dated [DATE] indicated he had been admitted from a short-term hospital. The MDS indicated he had a BIMS score of 7, which indicated he had severe cognitive impairment. The MDS indicated Resident #2 used a wheelchair for mobility. The MDS indicated Resident #2 was dependent on staff assistance for all ADLs, including eating. The MDS indicated Resident #2 was always incontinent of bowel and bladder.Record review of Resident #2's undated Care Plan with an admission date of 12/27/25 revealed the resident had an ADL self-care performance deficit related to confusion and impaired balance. The ADL intervention related eating stated the resident was able to feed himself with meal and tray set-up with a revision date of 8/20/25. The ADL care plan was not updated to show the resident was dependent on staff for eating.Record review of Resident #2's Order Summary Report dated 2/21/26 revealed an order for may have health shake if resident consumes less than 50 % of meal as needed. Encourage intake of health shake if less that 50 percent of any meal consumed and notify nurse with a start date of 5/08/24.Record review of Resident #2's Nursing Medication Administration Record dated 2/1/26-2/28/26 revealed an order for may have health shake if resident consumes less than 50 % of meal as needed. Encourage intake of health shake if less that 50 percent of any meal consumed and notify nurse. There was no documentation the resident received a health shake during the time period.Record review of Resident #2's Nutrition-Amount Eaten documentation revealed he consumed on:2/2/26-0-25% for one mealRefused one meal2/3/26-0-25% for one meal26-50% for 2 meals2/4/26-0-25% for one meal26-50% for 2 meals2/6/26-0-25% for two meals2/7/26-0-25% for one mealRefused one meal2/8/26-0-25% for two mealsNo documentation for 3rd meal2/9/26-0-25% for one mealNo documentation for two meals2/10/26-0-25% for one meal26-50% for one mealRefused one meal2/11/26-26-50% for one meal2/12/26Refused two meals2/13/26-0-25% for one meal26-50% for one meal2/14/26-Refused two meals2/15/26-0-25% for two mealsRefused one meals2/16/26-0-25% for one meal26-50% for one mealRefused one mealRecord review of Resident #2's weights indicated he weighed 158.6 pounds on 12/29/25 after discharging from the hospital on [DATE] and weighed 160.6 pounds on his last documented weight on 2/09/26.Record review of Resident #2's Nutritional Risk assessment dated [DATE] indicated his most recent weight was 160.6, he had a BMI of 22 (normal was 19-24.9), no weight changes were noted, his intake varied, and to continue current nutrition plan.Record review of Resident #2's nurses' notes from 2/1/26 through 2/16/26 did not indicate he had been offered or refused health shakes.During an interview on 2/21/26 at 4:26 PM, LVN B said she had worked at the facility for twelve years and had provided care for Resident #2. LVN B said the purpose of the comprehensive care plan was to let them know how to take care of the resident and what they needed. LVN B said if the care plan was not complete, the resident may not get the care or services they needed. She said if a resident had an order for a health shake if he consumed less than 50% of his meal, then they should have followed the physician's orders.During an interview on 2/21/26 at 5:22 PM, LVN C said she had worked at the facility for eleven years. LVN C said Resident #2 had a brain tumor and had a huge decline and even declined further after his last hospitalization in December 2025. LVN C said the comprehensive care plan purpose was to better take care of the resident. LVN C said it would have fall mats, if meds should be crushed, diet, anything that would be special for that person, disease processes, medications, ADL care, etc. LVN C said if the comprehensive care plan was not complete or inaccurate, then they may not know what care the resident needed and the resident could potentially not receive needed care/services. She said they should follow the physician's orders.During an interview on 2/21/26 at 6:15 PM, MDS Coordinator A said she had worked at the facility since August of 2025. She said the Comprehensive Care Plan was the responsibility of herself and another MDS Coordinator. She said the Comprehensive Care Plan should include areas related to code status, diet, allergies, assistance needed, skin, bowel and bladder, medications, risk of falls, risk of pressure ulcers, and health conditions. She said the purpose of the care plan was to communicate to all staff the needs of the resident. She said they had twenty-one days from admission to complete the comprehensive care plan. She said Resident #1's comprehensive care plan was not completed within the twenty-one days if he admitted on [DATE]. She said over the past week, she had been working the floor and may have missed Resident #1's comprehensive care plan, but it should have been completed within twenty-one days of admission. She said the comprehensive care should be a reflection of the comprehensive assessment and if Resident #2's comprehensive assessment stated he was dependent on staff assistance with meals, the comprehensive care plan should have also indicated he was dependent on staff for meals. She said if the Comprehensive Care Plan was not completed or was inaccurate, everyone may not know what was going on with the resident.During an interview on 2/22/26 at 1:49 PM, MD E said he had been Resident #2's physician for over twenty years and was also seeing him in the hospital. MD E said he did not remember being told Resident #2 was not eating well. MD E said Resident #2 had a history of significant weight loss and he had put medications in place and added health shakes. MD E said he would have expected his orders to have been followed for Resident #2 to have a health shake for eating less than 50% of his meals to prevent weight loss.During an interview on 2/22/26 at 2:41 PM, the DON said the MDS Coordinators were responsible for the comprehensive care plan but the IDT as a whole helped with updating and making changes. The DON said the MDS coordinators would be the ones to update the care plan at the time they were talking about it. The DON said the Comprehensive Care Plan told you how to take care of the patient overall and let you know of any changes. The DON said the Comprehensive Care Plan should include mobility, diet, code status, ADLs, incontinent status, fall risk, medications, disease processes, basically everything about the resident. The DON said if the Comprehensive Care Plan was not completed or inaccurate, you could miss on how to take care of the resident, or the resident could potentially not receive care/services they needed. The DON said the Comprehensive Care Plan should be followed. The DON said Resident #1 definitely should have had more than two problem areas. The DON said Resident #2 could not feed himself at all. The DON said if the staff did not know he needed assistance it could have potentially affected Resident #2, but the staff knew he needed assistance with meals. The DON said physician orders should be followed because it was a physician order and they should follow physician orders. The DON said a health shake would be important for the resident's nutrition. The DON said good nutrition was important for skin integrity and overall health.During an interview on 2/22/26 at 3:08 PM, the ADM said she had been the ADM for about two and a half weeks. The ADM said the Comprehensive Care Plan was how they cared for the resident. The ADM said the Comprehensive Care Plan should include diet, transfers, ADLs, behaviors, everything they needed to know to care for the resident the right way. The ADM said the Comprehensive Care Plan should be followed. The ADM said the risk to the resident if the Comprehensive Care Plan was not completed or was inaccurate could cause them to not meet the residents' needs and could throw off their care and it was important. The ADM said Resident #1 definitely should have had more than two problem areas. The ADM said Resident #2's Comprehensive Care Plan should have been updated to him being dependent on staff for meals. The ADM said she would expect the physician orders to be followed. The ADM said Resident #2 not receiving his health shakes when he consumed less than 50% of his meals, could have caused him to have unplanned weight loss and affected the healing process and skin integrity. The ADM said she would expect the facility policies to be followed.Record review of the facility's policy dated March 2022 and titled Care Plans, Comprehensive Person-Centered, indicated . A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident .1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 2. The comprehensive, person-centered care plan was 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 . 3. The care plan interventions were derived from a thorough analysis of the information gathered as part of the comprehensive assessment . 4. Each resident's comprehensive person-centered care plan was consistent with the resident's rights to participate in the development and implementation of his or her plan of care, including the right to: . g. receive the services and/or items included in the plan of care . 7. The comprehensive, person-centered care plan: a. included measurable objectives and timeframes; b. described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . e. reflected currently recognized standards of practice for problem areas and conditions . 11. Assessments of residents were ongoing, and care plans were revised as information about the residents and the resident's conditions change . 12. The interdisciplinary team reviews and updates the care plan . c. when the resident has been readmitted to the facility from a hospital stay .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for kitchen sanitation. The facility did not ensure: 1. Meat was thawing in the appropriate container and sink under constant flow of cool, running water during the initial tour on 02/26/2024.2. A container which held a thick pink liquid was labeled and dated. 3. A box of frozen biscuits, a box of frozen corn, a plastic bag of cheese, and a plastic bag of chicken nuggets were sealed appropriately in the refrigerator. 4. The potato freezer was free of rust on the bottom shelf inside the freezer. 5. The juice tubing was kept off the ground. These failures could place residents at risk for cross contamination and food-borne illness. The findings included: During an initial tour observation in the kitchen on 12/01/25 beginning at 8:05 AM, revealed the following:1. There was an open box of frozen biscuits and frozen corn in the vegetable freezer.2. There was a container which held a thick pink substance in the milk refrigerator, which was unlabeled and undated.3. There was an open plastic bag of yellow shredded cheese in the salad bar cooler.4. There was an open plastic, resealable bag of frozen chicken nuggets in the potato freezer. The bottom of the potato freezer had large brownish-yellow stains and a small layer of ice.5. There were two long packages of ground hamburger meat that was sitting at the bottom of the third sink on the three-compartment sink. There was no water running.6. The orange juice tubing was located on the ground in front of the juice boxes and was not connected to the box of juice. During an observation on 12/01/25 at 8:37 AM, the 2 long packages of ground hamburger meat were submerged by hot steaming water in the third sink of the three-compartment sink. The packages were not in a container and the water did not run continuously. During an interview on 12/03/25 beginning at 2:43 PM, [NAME] P stated she worked as the cook and as a dietary aide. She said everything was supposed to have been sealed, labeled, and dated. [NAME] P said on 12/01/25 the dietary staff were in the process of serving breakfast. She stated it was hard to ensure everything was sealed, labeled, and dated properly during the busiest times. [NAME] P stated the bottom of potato freezer was cleaned now. She said the potato freezer was cleaned every week according to a cleaning schedule. [NAME] P stated she had not gotten to clean the potato freezer on the morning of 12/01/25 before the surveyor completed the initial tour. She stated meat should have been thawed in a pan with cool water running constantly. [NAME] P stated it was important to ensure everything was properly sealed, dated, labeled, and cleaned to prevent food contamination. She said it was important to ensure meat was thawed appropriately to prevent bacteria growth and contamination of the food. She stated it was unsanitary. During an interview on 12/03/25 beginning at 3:33 PM, the Dietary Manager stated she expected the dietary staff to slow down during the meal services and pay attention to what they were doing. She stated all the dietary staff knew how to label, date, and package the food. She said the juice tubing should not have been on the ground. She said it was important to ensure food was sealed properly, labeled, dated, and tubing was kept off the ground for sanitary reasons. She stated it would have prevented freezer burn and food contamination. The Dietary Manager stated meat should have been thawed in a pan with cool water running continuously. She stated meat should not have been sitting in water. She stated it was important to ensure meat was thawed properly so residents did not become sick. During an interview on 12/03/25 beginning at 3:46 PM, the Interim Administrator stated he expected the dietary staff to ensure proper protocols were in place and followed for food administration. He stated the Dietary Manager was responsible for monitoring to ensure proper food preparation protocols were implemented. He said the Administrator was responsible for monitoring the Dietary Manager. He stated it was important to ensure proper food preparations protocols were implemented to prevent food contamination. Record review of the Food Safety policy, year dated 2012, reflected Food shall be handled in a safe manner.food is to be tightly wrapped or sealed and covered in clean containers.opened food shall be labeled, dated and stored properly. Record review of the Handling of Potentially Hazardous Foods policy, year dated 2012, reflected .never defrost foods of animal origins at room temperature. Record review of the Thawing Foods policy, year dated 2012, reflected All food will be thawed in a safe and sanitary manner.under potable running water temperature of 70 degrees or below, with sufficient velocity to agitate and float off loose food particles into the overflow, in a sealed package.

Based on observation, interviews, and record review, the facility failed to ensure complete and accurate documentation for 1 of 18 residents reviewed for medical records. (Resident #52.) 1. The facility did not ensure resident records were free from unauthorized use due to staff not having their own individual login for the (EHR). 2. The facility failed to ensure accurate and complete documentation was entered for Resident #52 related to her diabetes management and wound care. These failures could place residents at risk for inaccuracy of clinical records and the decrease continuity of resident care. Findings included:Record review of Resident #52 face sheet date 12/01/2025 revealed she was an [AGE] year-old female admitted on [DATE] with the primary diagnosis of Acute embolism and thrombosis of popliteal vein (blood clot forms in the popliteal veins located behind the knees, blocking blood flow), being treated postoperatively. Resident #52 has a medical history including type 2 diabetes mellites (chronic metabolic condition in which the body does not use insulin effectively, leading to elevated blood glucose levels), transient ischemia attack (temporary interruption of blood flow to the brain that causes stroke-like symptoms but does not result in permanent brain damage), hypertension (chronic medical condition of persistently elevated blood pressure level), and chronic obstructive pulmonary disease (progressive lung disease that causes airflow obstruction). Record review of a quarterly MDS assessment dated [DATE] revealed Resident #52 had a BIMS of 11 which indicated a moderate cognitive impairment. Resident #52 was usually understood others and usually made herself understood. Resident #52 required standby and set up assistance for ADLs such as eating, toileting, transfer, and bathing. The MDS assessment indicated she was being treated with antibiotic (treated infection) and hypoglycemic (treat low blood glucose level). Record review of Follow-up appointment case description from 09/22/2025 at 11:09AM indicated Resident #52 had a follow up appointment with MD on 9/22/2025 to remove stitches and would require the removal of the IVC filter on a later date. Record review of physician orders for Resident #52 dated 11/22/25 indicated treatment for bilateral lower extremity cellulitis, however, it was never addressed in the skin assessments nor the skin checks. Record review of the progress note dated 11/24/2025 noted she was taking an antibiotic for redness and warmth of left leg. Record review of the Skin assessments for Resident #52 dated 11/24/2025 at 1:26 PM, completed by LVN G revealed a boil on sacrum. The skin assessment indicated the following issues: Other (specify) Other (specify) and right buttock boil. The skin assessment did not reflect stage II Pressure or residual postoperative stitch. No other documentation or skin issues were provided on the skin assessment. Record review of EHR revealed Resident #52 on 11/28/2025 was identified as having a new identified stage 2 pressure injury to the sacrum when a physician's order was documented in the EHR which was put in by the wound care nurse. Resident #52's EHR failed to have a pressure injury/skin assessment including measurements, drainage, or surrounding tissue condition upon identification. Record review of the skin assessment schedule provided to surveyors by the wound care nurse on 12/02/2025 revealed skin assessments for Resident #52 were due every Monday. Record review of EHR revealed several progress note entries dating for the month of November 2025 for Resident #52 were recorded under the generic login 'Nurse2025', preventing identification of the staff member responsible for the entry. During an observation and interview on 12/01/2025 at 8:43AM Resident #52 was sitting in a chair eating breakfast. Resident #52 stated the surgeon left stitches on the top of her posterior calf. Resident #52 stated she reported these stitches to the nursing staff a few weeks ago, however, she could not recall who she had reported them to or an exact date or time. Resident #52 also stated she had reported pain, redness, and swelling to her anterior legs approximately near her shins where the condition of cellulitis (bacterial infection of the skin and underlying tissue), was being treated. Resident #52 said she was being treated with antibiotics for 10 days. During an interview with the wound care nurse on 12/01/2025 at 4:40 PM revealed the new pressure stage II was identified on Friday 11/28/2025 when the skin check was performed, however, no skin assessment was documented. The Wound care nurse stated she had standing orders from the wound care provider that she began on Friday. She had not seen or identified a postoperative stitch. The wound care nurse used previous wound care orders from treatments that Resident #52 had previously. She stated she put the new orders in; however, the wound care nurse stated she did not document a skin assessment. The wound care nurse stated a skin check was done on Friday before I left. I did it by hand on a notebook. I did not do my due diligence and put it into the computer before leaving my shift. I put the orders in so that she would receive the daily wound care over the weekend. The wound care nurse stated she was responsible for overseeing and ensuring that all skin assessments are completed, accurate and documented in accordance with standards. She stated this placed Resident #52 at risk for the care to be provided more than prescribed. During an interview with LVN L on 12/02/2025 at 9:37 AM, she stated she had not identified a pressure ulcer or postoperative stitch on the skin assessments she had performed; however, she cannot remember when she completed the last skin assessment on Resident #52. She stated that there was a schedule for each resident to have their skin assessment done weekly. 2) Record review and interview on 12/02/2025 at 9:00 AM of physician orders started on 09/03/2025 indicated Resident #52 was treated for type 2 diabetes mellitus with Humulin R insulin (short-acting insulin) inject as per sliding scale: if 150 - 200 = 3 units; 201 - 250 = 6 units; 251 - 300 = 9 units. Give 12 units for levels above 300., and finger stick blood sugar checks 3 times a day. Resident #52 reported her blood sugar had spiked recently. According to records and interviews with resident and LVN L she had started Lantus on 12/1/2025 for hyperglycemia. Record review of the physician orders indicated Resident #52 started Lantus (long-acting insulin) on 12/01/2025. Record review of Resident #52's medication administration record dated November 1, 2025- November 30, 2025, revealed elevated blood sugar levels on: 11/30/2025 at 11:28 a.m., the documented blood sugar level was 569, 11/29/2025 at 11:36 AM, the documented blood sugar level was 470, 11/27/2025 at 7:43 p.m., the documented blood sugar level was 307, 11/26/2025 at 11:33 a.m., the documented blood sugar level was 388, and on 11/21/2025 at 11:30 a.m., the documented blood sugar level was 331. The medication administration record indicated Nurse 2025 documented these blood sugar results and then documented a chart code of 9 indicating see Resident #52's progress notes. Record review of Resident #52's progress notes dated November 21, 2025- November 30, 2025, revealed there were no interventions listed for the elevated blood sugars. Record review on 12/01/2025 for November 1, 2025- November 30, 2025, of the facility EHR system revealed multiple nursing staff using the same login 'Nurse2025' at the same time while on different units. This inhibited the surveyors from being able to differentiate who was charting under each resident at that time. Records reviews revealed blood sugar for Resident #52 was charted under the user 'Nurse2025' seventy times in the month of November 2025 reviewed for documentation of blood sugar monitoring. During an interview with ADON on 12/01/2025 at 3:22 PM, the ADON stated all agency staff used one login and other staff including the weekend supervisor and the wound care nurse. She stated the login being shared was listed as Nurse2025. The ADON could not provide a complete list of staff and agency staff using this login. She voiced she was aware that this could be a potential problem and that it inhibited her from identifying who documented. During an observation on 12/01/2025 at 3:30PM LVN L was noted accessing and documenting in the EHR using a shared, non-individualized login. LVN L was noted to be entering information under the same generic username listed as 'Nurse2025' which was found to be used by LVN Q on different shifts. During an interview on 12/02/2025 9:37 AM, LVN L indicated Resident #52's blood sugar results had been elevated. LVN L stated on 11/30/2025 she contacted the nurse practitioner regarding Resident #52's blood sugar result of 569 at 11:30 AM and received an order for Lantus 10 units every morning. LVN L said the nurse practitioner reviewed Resident #52's blood sugars. LVN L stated nursing notes were used to document communications such as new orders, notification of change, and changes of condition. LVN L stated she had not yet put a note in as of 12/02/2025 because she had forgotten. She stated she texted the NP and was told to give 12 units Humulin R which was the highest dose ordered at the time. NP ordered to add Lantus to start the following morning and monitor for side effects of Lantus and hyper/hypo glycemia. LVN L stated she started this new medication for the blood sugar on11/30/2025 at 11:28 AM, the documented blood sugar level was 569. During an interview on 12/02/2025 at 9:36 AM, LVN L reported she did not have her own individualized EHR credentials and routinely used a shared or temporary agency account log in credentials for documentation. LVN L stated the facility had not issued or maintained unique logins for all personnel responsible for charting. LVN L said she was hired on 11/11/2026 and was not provided an unique login for herself. During an interview with LVN L on 12/02/2025 at 9:37 AM, she stated her login was not functioning, so she had to use the generic login 'Nurse2025' which is what agency staff use. LVN L stated it has not been functioning since her start date as of 11/11/2025. She reported the issue to the ADON who instructed her to use the generic login. LVN L stated when she signed into it, it auto populated by signing it. LVN L stated she should have put her name under it so if something happened it does not fall back on her while using that login in. LVN L stated it was important to have individualized logins, so no medication errors or double dosing happened if multiple people were using that login. She stated she would rather use her own login and not share. She stated sharing logins could cause harm to the residents. During an interview with LVN Q on 12/02/2025 at 3:25 PM, he indicated that all agency staff use the same agency login. He stated he could not go back and find his individual note with name attached to it. He stated he did not sign his notes with a signature he just put agency nurse. He stated at passed employers he was provided with an individualized login. LVN Q stated having individual login was a better system and protected the residents from possible errors and harm. During an interview with the DON on 12/03/2025 at 2:10 PM, she stated she expected documentation to be done on any care provided. The DON said a resident was at risk for inadequate/incomplete medical record when documentation was not done and this led to the inability to determine the care provided or not provided. The DON said she expected skin assessments to be done weekly to maintain good skin health and monitor skin barrier issues/breakdown. The DON said the documentation of skin assessments allowed nurses to implement new plan of care if there are any issues. The DON said the nurses complete the skin assessments and treatment wound care nurse oversees the assessments. DON stated all staff should have their own login to the EHR according to the policy and she was unaware of this issue until 12/01/2025 with surveyor intervention. During an interview with the Administrator on 12/03/2025 at 3:38 PM, he said he was not aware of all agency staff and other facility staff were using the same login. He stated that it was against facility policy. The Administrator said he expected all care provided to be documented by the staff providing the care in a timely manner prior to leaving their shift. He stated there was a possibility for harm to the residents, medical errors, and HIPPA violation. Record review of an Electronic Medical Records Policy dated March 2014 indicated Electronic Medical Records: Policy Statement: Electronic medical records may be used in lieu of paper records when approved by the administrator.Policy Interpretation and Implementation1. Electronic records are an acceptable form of medical record management.2. The administrator, in conjunction with the quality assurance and performance improvement committee, shall review requests for and the implementation of our electronic medical records system.3. Only authorized persons who have been issued a password and user ID code will be permitted access to the electronic medical records system.4. The facility will make reasonable efforts to limit the use or disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure.5. The HIPAA compliance officer, administrator and director of nursing services maintain a listing of each user ID code. Such listing is confidential and secured.6. When personnel changes occur, or there is reason to believe that unauthorized access to protected information has occurred, the HIPAA compliance officer, administrator and director of nursing services shall review the security of the information and change user ID codes if necessary. Record review of a Diabetes-Clinical Protocol dated December 2020 indicated:Documentation: The resident's blood glucose result, as ordered; The licensed nurse will initial the Medical Administration Record (MAR). The license nurse will document refuses. Record review of a Wound Care Policy updated July 2024 indicated:The following information should be recorded in the resident's medical record: The date the wound care was given. The initials of the individual performing the wound care. Any change in the resident's condition. Any problems or complaints made by the resident related to the procedure. If the resident refused the treatment and the reason(s) why. The signature and title of the person recording the data. Record review of a Charting and Documentation policy dated July 2017 indicated:All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Policy Interpretation and Implementation indicated documentation in the medical record may be electronic, manual or a combination. The following information is to be documented in the resident medical record:a. Objective observations;b. Medications administered;c. Treatments or services performed;d. Changes in the resident's condition;e. Events, incidents or accidents involving the resident; andf. Progress toward or changes in the care plan goals and objectives.Documentation in the medical record will be objective (not opinionated or speculative), complete, andaccurate.Entries may only be recorded in the resident's clinical record by licensed personnel (e.g., RN, LPN/LVN, physicians, therapists, etc.) in accordance with state law and facility policy. Certified nursing assistantsmay only make entries in the resident's medical chart as permitted by facility policy.Information documented in the resident's clinical record is confidential and may only be released in accordance with state law, the Health Insurance Portability and Accountability Act (HIPAA) and facility policy. Refer all requests for information to the director of nursing services, nurse supervisor/charge nurse or to the business office.To ensure consistency in charting and documentation of the resident's clinical record, only facility approved abbreviations and symbols may be used when recording entries in the resident's clinical records.Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided;the name and title of the individual(s) who provided the care;the assessment data and/or any unusual findings obtained during the procedure/treatment; how the resident tolerated the procedure/treatment;whether the resident refused the procedure/treatment;notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting. Record review of a Skin System Process policy dated October 2025 indicated Skin Assessment (UDA-Skin Assessment V2): Conduct a full head-to-toe assessment every 7 days. New in-house acquired pressure injuries require an incident report and appropriate follow-up. PCC Skin and Wound Total Body Assessment (Skin & Wound Module): (Use Wound Assessment Profile 3.0- V2 until Skin & Wound Module enabled). Complete weekly until all pressure injuries or skin issues (e.g., skin tears, lacerations, abrasions, surgical incisions, diabetic, arterial, stasis, venous ulcers) are resolved.The treatment nurse (if applicable) is responsible for keeping the skin system up to date. However, if the treatment nurse is assigned to work as a charge nurse, it becomes your responsibility to ensure that skin assessments are completed on time. If there is no treatment nurse, charge nurses can conduct skin assessments. You are required to verify the assessments at least once a month to ensure their accuracy.

Based on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 1 dining room and 3 of 22 residents reviewed for environment. (Resident #18, Resident #40, and Resident #57) 1. The facility failed to repair wall damage in the rooms of Resident #18, Resident #40, and Resident #57 in a timely manner. 2. The facility failed to repair peeling wallpaper above the bed of Resident #40. 3. The facility failed to repair a leaking skylight, clean two vents, and missing texture in the ceiling of the dining room. These failures could place residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth. During an observation on 12/01/25 at 12:16 p.m., it was raining heavily outside. There was water dripping into a bucket sitting on a table from a skylight in the dining room. There was a puddle of water under the table approximately 8 inches by 11 inches. There was a discolored area around the drip. The discolored area was black and yellow in color. A resident sitting approximately 7 feet away with approximately 3 other residents sitting at the same table. The vent #3 near sky light was covered with a black substance. Texture was missing from ceiling in dining room around vent #1. The sheetrock was exposed. Vent #2 near a second skylight had a gray substance covering it. During an observation on 12/02/2025 at 7:12 a.m., the skylight in the dining room was not dripping. The bucket was on floor under the edge of the table. There was a discolored area around the drip. The discolored area was black and yellow in color. There was a black substance scattered throughout the skylight. Vent #3 near skylight was covered with a black substance. Texture was missing from the ceiling in the dining room around vent #1. The sheetrock was exposed near vent #1. Vent #2, near a second skylight, had a gray substance covering it.1. Record review of the face sheet, dated 12/02/25, indicated Resident #18 was [AGE] years old and admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease (lung disease), major depressive disorder (a mental health condition characterized by persistent feelings of sadness and a loss of interest or pleasure in daily activities, affecting an individual's ability to function), shortness of breath and legal blindness. Record review of a quarterly MDS assessment, dated 11/03/25, indicated Resident #18 was understood and understood others. The MDS indicated a BIMS score of 12 indicating Resident #18 was moderately cognitively impaired. The MDS indicated Resident #18 required moderate assistance from staff with ADLs.During an observation on 12/01/25 at 10:36 a.m., Resident #18 was sleeping in his bed. There was an area of exposed sheetrock between the wall and the head of this bed. The area was approximately 12 inches in length and was gaping open vertically and the first layer of paint and sheetrock was peeling away from the area. During an observation on 12/02/25 at 10:52 a.m., Resident #18 was sleeping in his bed. There was an area of exposed sheetrock between the wall and the head of this bed. The area was approximately 12 inches in length and was gaping open vertically and the first layer of paint and sheetrock was peeling away from the area.During an observation and interview on 12/02/25 at 2:05 p.m., there was an area of exposed sheetrock between the wall and the head of this bed. The area was approximately 12 inches in length and was gaping open vertically and the first layer of paint and sheetrock was peeling away from the area. Resident #18 was in bed. He said he was blind, and he became aware of the area when he dropped his electronic device and bent down to pick it up. He said the wall had been that way since he moved into the room. He said he did not know how long his roommate's (Resident #57) wall had been damaged. He said he heard the Maintenance Supervisor tell his roommate he was going to repair the damage to his wall. He said that was approximately 3 - 4 weeks ago. 2. Record review of the face sheet, dated 12/02/25, indicated Resident #40 was [AGE] years old and admitted on [DATE] with diagnoses including generalized anxiety disorder, depression, and chronic pain syndrome. Record review of a quarterly MDS assessment, dated 10/23/25, indicated Resident #40 was understood and understood others. The MDS indicated a BIMS score of 11 indicating Resident #40 had moderately cognitively impairment. The MDS indicated Resident #40 required moderate assistance with most ADLs. During an observation and interview on 12/01/25 at 10:05 a.m., Resident #40 was in bed. There was peeling wallpaper above the bed near the ceiling. There was an area of paint missing beside the bed. The sheetrock was exposed on the wall beside her bed. Resident #40 said the area on the wall and the peeling wallpaper had been that way since she was placed in the room. She said the wallpaper and the paint missing on the wall made her feel like rats could come into her room.During an observation 12/02/25 at 10:50 a.m., Resident #40 was not in her room. There was peeling wallpaper above the bed near the ceiling. There was an area of paint missing beside bed, exposing the sheetrock underneath. 3. Record review of the face sheet, dated 12/02/25, indicated Resident #57 was [AGE] years old and admitted on [DATE] with diagnoses including heart disease (a range of conditions that affect the heart), chronic fatigue, and back pain.Record review of a quarterly MDS assessment, dated 11/08/24, indicated Resident #57 was understood and usually understood others. The MDS indicated a BIMS score of 10 indicating Resident #57 had moderate cognitive impairment. The MDS indicated Resident #72 required a walker to ambulate and supervision for some ADLs. During an observation on 12/01/25 at 10:36 a.m., Resident #57 was sleeping in bed. On the wall beside his bed there was a large area of exposed sheetrock and four smaller areas. There were areas of missing paint, exposing sheetrock underneath. During an observation on 12/02/25 at 2:29 p.m., Resident #57 was in bed. On the wall beside his bed there was a large area of exposed sheetrock and four smaller areas. There were areas of missing paint, exposing sheetrock underneath.He said he did not know how long there was damage to his wall and he did not remember the maintenance man speaking to him about the damage.During an interview on 12/02/25 at 2:22 p.m., the Regional Nurse said there was not a maintenance repair log. She said maintenance request were entered into an electronic system. During an interview on 12/02/25 at 3:26 p.m., Housekeeper N said the skylight in the dining room had been leaking for at least eight months. She said there were no attempts at repairs that she was aware of. During an observation and interview 12/02/25 at 3:30 p.m., the Dietary Manager said approximately one year ago an attempt was made to repair the leaking skylight. She said when it rained hard outside it leaked really bad. She said when it slightly rained it did not leak badly. She said the leak was from something on the roof. She said everyone was aware of the leak. She said when the skylight leaked staff put a bucket under the drip. She said they tried to move residents away from the area when it leaked. She said she did not know how long the sheetrock was exposed around vent #1. She said vent #2 appeared to be dirty. She said it looked dusty. She said vent #3 near the leaking sky light looked moldy. During an interview on 12/03/25 at 8:33 a.m., LVN G said the leak around the skylight had been there as long as she could remember and she was employed at the facility 11 years. She said there were multiple repair attempts. She said she noticed the yellow and black discoloration in the skylight. She said she felt like this area was water damage and mold. She said she had not noticed the wallpaper peeling in Resident #40's room. She said she had not noticed the area by Resident #40's bed. She said staff should notice walls in disrepair when they entered a room and it should be reported to maintenance. She said maintenance issues were reported through an electronic system. She said the areas in Resident #18 and Resident #57's room had been there several months. She said she reported it to maintenance in the past and did not know why it was not repaired. She said walls being in disrepair could lead to dust coming from the area and cause residents to have respiratory issues. During an interview on 12/03/25 at 9:21 a.m., the Wound Care Nurse said the skylight in the dining room only leaked if the rain poured. She said she had been aware of the leak for approximately six months. She said the water was usually caught in the bucket. She said she thought maintenance addressed the leak in the past. She said she had not noticed the discoloration on the skylight. She said the leak could cause a resident to slip and fall. She said if staff did not pull the beds away from the wall it would cause damage exposing the sheetrock. She said she had not noticed the wallpaper in Resident #40's room. She said staff noticing disrepair should put in an electronic work order. She said disrepair was unsightly and a pest control issue. During an interview on 12/03/25 at 10:12 a.m., CNA M said maintenance repaired the walls, but moving the beds kept damaging the walls. She said she never noticed the wallpaper peeling in Resident #40's room. She said there used to be a book at the nurse's station for maintenance repair request or you could tell maintenance verbally. She said she noticed the walls in Resident #18's and Resident #57's room approximately a week or two ago. She said she reported it verbally to the Maintenance Supervisor. She said the skylight leaked in the dining room for years. She said there were attempts to repair it in the past. She said it leaked when it rained heavy and a bucket was placed under the leak. During an interview and observation on 12/03/25 at 10:55 a.m., the Maintenance Supervisor said over the last couple of months he had been pulling down vents, sanding them down, and cleaning them. He said he felt vent #2 and #3 in the dining room were missed. He said he was not aware of the texture missing around vent #1 in the dining room. He said it had not been reported to him. He said the skylight had been leaking a while . He said he could not say how long. He said he had been on the roof for repairs. He said he used a compound to repair the leak and then the heat cracked it and then it would dry rot. He said the discoloration on the skylight was approximately 2 feet by 8 inches. He said the discoloration was from water damage. He said vent #3 did have a little bit of black spotting. He said he felt like the black areas near and on the skylight were dust. He said he was on the roof 12/02/25 and there was a huge crack right where you don't want it. He said any staff needing to place a maintenance request should enter work orders into the electronic system. He said they had access on all computers in the facility. He said the wallpaper was put back up in Resident #40's room with glue and it had fallen back down. He said he found out about the wallpaper being back down today (12/03/25). He said Resident #40 reported the damage to her wall to him on 12/01/25. He said he was unaware of the damage in Resident #18's and Resident #57's room until this interview. This surveyor observed the areas with the Maintenance Supervisor. He said the paint and the top layer of the sheetrock had been torn and exposed the sheetrock. He said he expected the issues to be reported to him. He said he would not want his home to look that way.During an interview on 12/03/25 at 11:22 a.m., the ADON said she recently started seeing, over the last month or two, a trash can in the dining room under the skylight catching water. She said they had some guys out doing work on the roof, but she did not know what happened with that. She said she thought they did not come back and had put the Maintenance Supervisor in a bad spot. She said she had not noticed the discolored area or the black substance. She said she noticed dirty vents and the missing texture from the ceiling in the dining room. She said the leaking could cause a resident to fall. She said particles dropping from the ceiling could cause respiratory issues or particles to fall into the resident's food. She said maintenance issues were reported electronically. She said the Maintenance Supervisor was good about getting stuff done. She said she would have expected staff entering residents' room, to report any damage to the walls or wallpaper to the maintenance supervisor. She said she would then expect the damage to be repaired in a timely manner. She said damage in rooms could cause injuries such as skin tears. She said she absolutely would not want her home to look that way. She said it had a major impact on how the residents felt about where they lived.During an interview on 12/03/25 at 1:07 p.m., the Regional Nurse said any staff were to report any damage through an electronic system to the maintenance supervisor. She said it was the responsibility of the maintenance supervisor to make the repairs or get a plan together for repair to be done in a timely manner. She said maintenance was responsible for repairing the leaking skylight. She said she was new to the building and had no idea how long it had been leaking. She said all of the damage not repaired was a failure to provide the residents a comfortable home-like environment.During an interview on 12/03/25 at 1:21 p.m., the Administrator said he expected the walls and wallpaper to have at least been on a list to be repaired. He said any staff entering a resident's room should notice damage in the rooms and use the electronic system to put work orders in . He said repairs not made caused residents to not have a homelike environment. He said he expected for the roof/skylight to be repaired. He said vents should be inspected regularly and kept clean. He said the vent with the missing texture should have been reported and repaired. He said the leak, dirty vents, and roof not repaired in the dining room could have a detrimental effect on a resident and not provide a clean comfortable homelike environment. Record review of a Maintenance Service facility policy last revised on 12/2009 indicated, Maintenance service shall be provided to all areas of the building, grounds, and equipment.The maintenance department is responsible for maintaining the building.at all times.Functions of maintenance personnel include.maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.maintaining the building in good repair and free from hazards.

Based on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 3 of 5 residents (Resident's #3, #16, and #75) reviewed for palatable food. The facility failed to provide food that was palatable and attractive to Resident #3, #16, and #75 who complained the food was served cool and bland. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life. The findings included: 1. Record review of an undated face sheet revealed Resident #3 was an 77- year-old-male, admitted on [DATE] with the diagnoses of diabetes type II (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels, atrial fibrillation (common type of irregular and often rapid heart rhythm where the upper chambers of the heart quiver instead of beating effectively), and insomnia (common type of irregular and often rapid heart rhythm where the upper chambers of the heart quiver instead of beating effectively). Record review of an admission MDS assessment dated [DATE] for Resident #3 revealed a BIMS of 13, which reflected no cognitive impairment. The MDS also revealed Resident #3 required set-up only staff assistance with eating. Record review of the MD orders dated December 2025 revealed an order for a regular consistency, cardiac diet. During an interview on 12/01/25 at 8:15 AM, Resident #3 stated the food was tasteless. He stated the food tasted like air or plain water. Resident #3 stated tasteless food made the food unappetizing to him and he often left half of his food uneaten. During an observation and interview on 12/01/25 at 12:40 PM, Resident #3 consumed less than 50% of the lunch meal. Resident #3 stated the food was bland and not something he wanted to finish. 2. Record review of an undated face sheet revealed Resident #16 was a 74- year-old-female, admitted on [DATE] with the diagnoses of multiple sclerosis (an autoimmune disease that damages the myelin sheath, the protective covering of the nerves in the brain and spinal cord, leading to disrupted communication between the brain and body), seizure (sudden surge of abnormal electrical activity in the brain that can cause a range of symptoms, from brief confusion or a strange sensation to severe convulsions), and morbid obesity (a body mass Index (BMI) of 40 or higher, or a BMI of 35 or higher with at least one obesity-related health condition). Record review of an annual MDS dated [DATE] for Resident #16 revealed a BIMS of 15, which indicated no memory impairment. The MDS also revealed Resident #15 required set up only assistance with eating. Record review of a care plan dated 09/16/25 revealed Resident #16 was receiving a regular diet with no restrictions. During an interview on 12/01/25 at 9:35 AM, Resident #16 stated the food tasted bland and not seasoned at all. Resident #16 stated she ate in her room most days because the environment in the dining room was not appetizing either. Resident #16 stated it was not a particular day, meal, or cook that was worse or better. Resident #16 stated cereal was the most flavorful meal that was served at the facility. During an observation and interview on 12/02/25 at 12:40 PM, Resident #16 stated the mashed potatoes served for lunch tasted exactly like air. She stated she could tell they were instant and had no salt, pepper, butter, garlic powder, or spice at all. Resident #16 consumed less than 50% of the meal. During an interview on 12/03/25 at 11:00 AM, the Regional Nurse stated she was unaware of the complaints about the taste of food. She stated there was no reason that no salt was used to season food, that she was unaware the kitchen was not using pepper. The Regional Nurse stated there was a great number of spices that could be used to flavor food, if dietary restrictions or allergies were the issue for flavorless food. During an interview on 12/03/25 at 1:00 PM, the Administrator stated he was aware the residents complained about the blended vegetables. He understood the problem to be with the consistency of the vegetables and not the flavor. He stated it was discussed in the previous resident council meeting and addressed by the dietary staff. He stated not using salt and pepper according to the recipe for residents with no restrictions was not acceptable practice. He stated flavorless food could lead to weight loss and decline. 3. Record review of the face sheet dated 12/03/25 indicated Resident #75 was a [AGE] year-old male who was re-admitted on [DATE] with diagnosis which included atrial fibrillation (an irregular heart rhythm that originates in the heart's upper chambers) , urinary tract infection (an infection in any part of the urinary system), chronic pain ( a persistent pain condition that lasts for more than 3 months affecting the quality of life) and atherosclerotic heart disease of native coronary artery without angina pectoris (a progressive disease where plaque, composed of fat, cholesterol, calcium and other substances, accumulates in the walls of the arteries). Record review of Resident #75's MDS assessment, dated 09/25/25, indicated Resident #75 was usually understood and usually understood by others. The MDS also indicated Resident #75 had a BIM score of 11 indicating moderate cognitive impairment. The MDS indicated Resident #75 was independent with eating, and oral hygiene. Record review of the undated care plan indicated Resident #7 had potential nutritional problems related to chronic pain syndrome (a persistent pain condition that lasts for more than 3 months affecting the quality of life), major depressive disorder (a mood disorder that causes persistent feeling of sadness and loss of interest). Interventions included monitor/document and report signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat or appears concerned during meals. Monitor/record/report to MD as needed signs and symptoms of malnutrition, emaciation (Cachexia) (a complication of severe chronic diseases like cancer and heart failure that causes weight loss), muscle % in 3 months, significant weight loss such as 3 pounds, in 1 week, > % in 1 month, >10 % in 6 months, provide and serve diet as ordered, monitor intake and record each meal, and weigh and record per MD orders. During an interview on 12/01/25 at 2:15 PM Resident #75 said the food was awful. He complained of the food being refrigerator cold. During an observation and interview on 12/02/25 beginning at 12:40 PM, the Dietary Manager stated the lunch meal tray consisted of Swiss steak, broccoli, mashed potatoes, and a dinner roll. The Dietary Manager and five surveyors tasted the meal tray. The Dietary Manager said the broccoli was lukewarm and bland. She stated the mashed potatoes had no flavor and could have been warmer. She stated she had received food complaints from the residents about too much salt. She also stated one of the residents were allergic to pepper, so the dietary cooks did not use pepper in the cooking. During an interview on 12/03/25 beginning at 2:43 PM, [NAME] P stated she had not received any complaints about the taste or temperature of the food. [NAME] P stated the dietary staff usually followed the recipes when cooking. [NAME] P stated the dietary staff did not use pepper because they had a resident allergic to pepper. [NAME] P stated she usually tasted the food to ensure the food tasted well. She said it was important to ensure the food looked good, tasted good and was at the appropriate temperature so the residents ate and did not lose weight. During an interview on 12/03/25 beginning at 3:33 PM, the Dietary Manager stated she had received food complaints regarding vegetables being too hard, so the dietary staff try to cook them a little softer. The Dietary manager said she had gotten food complaints about the seasoning when one particular cook was scheduled for cooking. She stated she used less seasoning than other cooks. The Dietary Manager stated she tried to taste the food daily before it was served but did not have time on 12/02/25. She stated it was important to ensure the food tasted good, looked appetizing, and was served at an appropriate temperature because the facility was their home and it encouraged them to eat. She said the dietary staff needed to cater to the resident's needs. During an interview on 12/03/25 beginning at 3:46 PM, the Interim Administrator stated he expected the dietary staff to follow the recipes. He said most of the food complaints were about the softness of the vegetables. He stated he ate at the facility daily, and some days the food was good and some days it was not as good. The Interim Administrator stated the Dietary Manger was responsible for monitoring the food quality. He said it was important to ensure the food looked good, tasted good, and was served at the appropriate temperature to ensure the residents would eat the food. Record review of the Preparation of Foods policy, year dated 2012, reflected We will establish safe and nutritional preparation of food. Food is to be prepared in such a manner as to maximize flavor, appearance, and nutritional value. all food will be prepared by methods that preserve nutritive value, flavor, and appearance with a variety of color, and will be attractively served at the proper temperature the Dietary Service Manager and cooks will taste and test meals daily.

Based on interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 18 residents reviewed for ADL care (Residents #3). The facility did not bathe Resident #3 from 11/19/2025 to 12/02/2025. This failure could place residents at risk of not receiving care and services to meet their needs, feelings of poor self-esteem, and lack of dignity and health.Record review of an undated face sheet revealed Resident #3 was a 77- year-old-male, admitted on [DATE] with the diagnoses of diabetes type II (a chronic condition where the body doesn't use insulin properly, leading to high blood sugar levels, atrial fibrillation (common type of irregular and often rapid heart rhythm where the upper chambers of the heart quiver instead of beating effectively), and insomnia (common type of irregular and often rapid heart rhythm where the upper chambers of the heart quiver instead of beating effectively). Record review of an admission MDS assessment, dated 09/24/2025, for Resident #3 revealed a BIMS of 13, which indicated no memory impairment. The MDS also revealed Resident #3 required substantial assistance with personal hygiene and bathing. Record review of a undated form titled shower schedule revealed Resident #3's designated bath days were every Monday, Wednesday, and Friday on the 2-10 shift. During a record review Resident #3's ADL sheet for bathing for November 1st to November 30th, revealed one documented bath in November 2025 on November 19th. There were no other documented baths for Resident #3 in the month of November 2025.During an interview on 12/03/2025 at 9:20 a.m., CNA B stated Resident #3 was to receive his shower on Monday, Wednesday, and Friday on the 2:00 p.m.- 10:00 p.m. shift. She stated she often worked over on the 2:00 p.m. -10:00 p.m. shift when the facility needed extra staff. She stated she never had a problem giving each resident a bath on any shift. CNA B stated Resident #3 required substantial assistance with all ADLs except eating and brushing his teeth. CNA B stated Resident #3 had never refused care and she had worked with him since he admitted . During an observation and interview on 12/01/2025 at 8:15 a.m., Resident #3 stated he only had one bath in November 2025 around the 20th. Resident #3 stated he was supposed to get a bath every Monday, Wednesday, and Friday on the 2:00 p.m.- 10:00 p.m. shift, but every time he asked the staff had an excuse why they could not assist him that day. Resident #3 stated he was always a clean person that bathed regularly and being dependent on people that were unwilling to assist him with a basic human need made him angry. Resident #3 stated his daughter visited often, but he did not feel comfortable asking his daughter to bathe him. Resident #3 appeared unshaven and had mild body odor. Resident #3 stated he would not name the CNAs he asked for a bath because he did not want to get anyone in trouble. During an interview on 12/03/2025 at 10:20 a.m., CMA H stated she worked as a CNA on the 2:00 p.m.- 10:00 p.m. shift all the time. CMA H stated Resident #3 was not known to refuse care. She stated sometimes on the 2:00 p.m.- 10:00 p.m. after supper there would be less staff and getting to all the showers could be challenging. CMA H stated 6:00 a.m.- 2:00 p.m. CNAs stayed over to help out until 6:00 p.m. During an interview on 12/03/2025 at 11:00 a.m., the Regional Nurse stated it was an expectation for all showers to be given as scheduled. She stated it was an expectation the nurse be notified, and documentation occur if any resident had not received a shower or bath on their scheduled bath day. The Regional Nurse stated it could make the residents feel uncomfortable and uncared for if they missed baths. During an interview on 12/03/2025 at 1:50 p.m., the Administrator stated all baths should be given according to the schedule and when the resident asked for one. He stated it did not matter if the resident requested a shower on a non-bath day it should be given. He stated it could make the residents feel uncared for and that was unacceptable. Record review of an undated policy titled Bathing, indicated .the resident acknowledges that skin feels clean and refreshed, and patient feels relaxed. Sweat, oil, dirt, and microorganisms are removed from resident's skin, and circulation is stimulated. Skin is free of excretions, draining, odor, rashes, irritation, excessive dryness, or breakdown. The resident tolerates procedure without fatigue, shortness of breath, or chilling.

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #81 and Resident #83) reviewed for infection control. 1. The facility failed to ensure the LVN L followed the Enhanced Barrier Precautions (EBP) (interventions to prevent spread of infection in high-risk residents) policy of wearing a gown during Resident #81's catheter assessment on 12/1/2025. 2. The facility failed to ensure the ADON followed the Enhanced Barrier Precautions policy of wearing a gown and gloves during an observation of Resident #81's catheter bag on 12/2/2025. 3. The facility failed to ensure CNA J followed the Enhanced Barrier Precautions policy of wearing a gown during Resident #83's catheter care on 12/2/2025.These failures could place residents at risk for cross-contamination, increased risk of infection and the spread of infection. Findings included:1. Record review of Resident #81's face sheet dated 12/2/2025 indicated Resident #81 was a [AGE] year-old, male and readmitted on [DATE] with diagnoses including cerebral infarction (a medical condition characterized by the interruption of blood supply to the brain), atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (characterized by the buildup of plaque in the coronary arteries, leading to narrowed or blocked arteries which can cause (angina) chest pain), essential hypertension (characterized by consistently high blood pressure readings,, typically defined as a systolic pressure of 130 mmHG or higher and/or a diastolic pressure on 80 mmHg or higher), and benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate can cause symptoms that can block the flow of urine out of the bladder), and chronic cystitis with hematuria (a long-lasting inflammation of the bladder that can cause symptoms such as pelvic pain, frequent urination and urgency). Record review of Resident #81's care plan initiated 5/1/2024 indicated Resident #81 had an indwelling foley catheter: Atonal bladder (a condition where the bladder muscles cannot contract fully), neurogenic bladder (a condition where nerve damage affects bladder control leading to issues such as urinary incontinence or retention), benign prostatic hypertrophy obstructive uropathy and retention of urine (a common condition that can lead to urinary retention due to the obstruction caused by the enlarge prostate). Intervention included to change catheter every month and PRN for failure to drain, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks and maintain the drainage bag off the floor, enhanced barrier precautions; post EBP sign in room, gown, gloves to be worn during high-contact resident care with indwelling medical device, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter, and monitor/record/report to MD for signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status and change in behavior, and eating patterns. Record review of a quarterly MDS dated [DATE] indicated Resident #81 had a BIMS score of 6 indicating he had severely cognitive impairment. Resident #81 was able to make self-understood and understood others. The MDS indicated Resident #81 had an indwelling catheter and required assistance for personal hygiene. Record review of Resident #81's care plan initiated on 5/6/2024 indicated Resident #81 had behavioral problems related to fascination with foley catheter tubing and privacy bags. Resident #81 would sit on tubing, remove privacy bag, refused to reposition, wraps tubing around body, thinks privacy bag was a belt, lifts bag above bladder level at times, and empties foley catheter at times. Interventions included: administer medications as ordered. Monitor and document for side effects and effectiveness, anticipate and meet the resident's needs, and evaluate for leg bag if appropriate.During an observation on 12/1/2025 at 8:25 AM, LVN L came in the room to assess Resident #81's catheter. She grabbed gloves from the nurse station and came to his room. LVN L did not place on PPE while assessing catheter for Resident #81. Resident #81 had a container at the door, a yellow sticker on door and an EBP precaution sign posted. During an observation on 12/2/2025 at 9:18 AM, the ADON was requested to assist Resident #81 who was in the hallway attempting to navigate in his wheelchair. The ADON said Resident #81 had labs ordered yesterday and she was waiting for the results. The ADON assessed the catheter bag without gloves or gown in the hallway. 2. Record review of Resident #83's face sheet dated 12/3/2025 indicated Resident #83 was a [AGE] year-old, male and readmitted on [DATE] with diagnoses including sepsis due to Escherichia coli (can occur when the bacteria enter the bloodstream leading to severe symptoms) , candidal cystitis (a rare urinary tract infection caused by an overgrowth of candida fungus, leading to inflammation and painful urinary symptoms) urethritis ( inflammation (swelling and irritation) of the urethra), chronic obstructive pyelonephritis (a long-term kidney infection that occurs when there is an obstruction in the urinary tract, often due to conditions like kidney stones or tumors), neuromuscular dysfunction of bladder (a condition that affects bladder function due to nervous system problems) and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (hemiplegia refers to complete paralysis of one side of the body, while hemiparesis indicates partial weakness. Both conditions are common after a stroke and occur when the brain's motor control areas are damaged). Record review of Resident #83's care plan initiated 5/1/2024 indicated Resident #83 had an indwelling foley catheter related to neurogenic bladder. Interventions included positioning catheter bags and tubing below the level of the bladder and away from entrance room door, check tubing for kinks and maintaining the drainage bag off the floor, enhanced barrier precautions; post EBP sign in room, gown, gloves to be worn during high-contact care with indwelling medical device. Resident #83's care plan indicated staff must wear gowns and gloves during high-contact resident care activities that could result in transferring MDROs to hands and clothing of staff. Interventions include staff washing hands or using alcohol-based gel when entering and exiting the resident room, sign for EBP precautions will be outside residents' room, to alert staff of precautions with direct care procedures and gowns will be available in room for staff to don when performing direct care with resident. During an observation on 12/2/2025 at 3:17 PM, CNA J provided Resident #83 with catheter care. CNA J washed her hands prior to care and did not don (put on) a PPE. Resident #83 was observed with a sign posted on the door indicating Resident # 83 was on EBP precautions and a container at his door with PPE available. During an interview on 12/2/2025 at 3:41 PM, CNA J said stood for Extra Barrier Precautions. She said residents who had foley catheters, feedings, dialysis, and central lines were on EBP. She said the staff were required to wear gloves. CNA J said she got nervous and forgot to put a gown on during care. CNA J said the ADON, and treatment nurse were responsible for ensuring staff were wearing proper PPE. CNA J said the staff had been in-serviced on EBP. She said it was important to wear proper PPE to prevent the spread of infection or cross contamination. During an interview on 12/3/2025 at 9:34 AM CNA K said she knew a resident was on EBP when there was a sign on the door. She said that was when the staff glove and gown up. CNA K said residents who had catheter and infections were on EBP. CNA K said PPE was used to prevent staff from getting an infection or spreading an infection. CNA K said CNA J, ADON and DON were responsible for ensuring staff wore proper PPE. During an interview on 12/3/2025 at 10:53 AM, LVN G said EBP stood for Enhanced Barrier Precautions. She said it was extra precautions for residents who had catheters, PICC lines (peripherally inserted central catheter is a long thin tube that was inserted through a vein in the arm) IV therapy (Intravenous therapy for medication administration), and Peg tubes (gastrostomy tube that allows means to provide nutrition). LVN G said there was a yellow sticker on the resident door indicating the resident was on precautions. LVN G said the staff should be wearing gowns and gloves to prevent infection. She said a resident could get an infection and get sepsis (occurs when your immune system has a dangerous reaction to an infection causing inflammation throughout the body that can lead to tissue damage, organ failure and even death). LVN G said it was the responsibility of ADON, DON to ensure staff were wearing proper PPE. LVN G said she had been trained and in-serviced on EBP. She said PPE should be worn while providing catheter care or direct care. During an interview on 12/3/2025 at 11:05 AM, ADON said residents who had peg tubes (gastrostomy tube that allows means to provide nutrition), wounds, feedings, tracheostomy (a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised) and catheters were on EBP. The ADON said the EBP were part of the staff's initial training. She said the facility had yellow stickers on the door and a container outside the resident room. She said it prevents the spread of bacterial or viral infection. The ADON said it was to protect the staff and residents from infection. The ADON said she expected the staff to wear PPE when a resident was on EBP precautions. The ADON said not wearing PPE could cause the residents to get an infection or get worse if they had an infection. She said not wearing proper PPE could also cause cross-contamination among other residents. The ADON said she is responsible for ensuring staff is wearing PPE. The ADON said she was not wearing gloves while looking at Resident #81's catheter in the hallway. The ADON said she should have been wearing it but wanted to take a brief look at the catheter bag. During an interview on 12/3/2025 at 1:20 PM, the DON said she expected the nurses to adhere to the facility policy for infection control and enhanced barrier control measures and wear proper PPE to prevent any organism that could cause infection. The DON said anyone with a wound, medical device such as catheter or PICC line or history of colonized MDRO. The DON said the sign tells them what to put on. She said it puts the resident at risk for infection. The Regional Nurse said she was responsible for ensuring the staff are wearing proper PPE. The Regional Nurse said she had serviced the previous DON on EBP and PPE. During an interview on 12/3/2025 at 1:35 PM, the ADM said he expected the staff to follow infection control policy. He said he saw the staff had in-services previously. The ADM said the facility had work to do on educating staff on infection control and EBP and wearing proper PPE. The ADM said not wearing proper PPE could cause infection. The ADM said the Regional Nurse was responsible for ensuring proper PPE was worn.Record review of a facility policy titled Enhanced Barrier Precautions dated February 2025 indicated .Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targets gown and glove during high contact resident care activities.Policy and Interpretation and Implementation.1. Enhanced barrier precautions (EBPs) were used as an infection prevention and control intervention to reduce the transmission of multi-drug-resistant organisms (MDROs) to residents. 2. EBPs employ targeted gown and glove use in addition to standard precautions.3. High contact resident care activities .dressing, bathing/showering, transferring, providing hygiene, changing lines, changing briefs.4.for residents infected or colonized with a CDC targeted or epidemiologically important MDRO, including.pan-resistant organisms.has a wound or indwelling medical device, secretions or excretions that are unable to be covered or contained and are not known to be infected of colonized.5. EBP were indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.6. EBP remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device. 7. The use of EBPs does not impose limitations on group activities.8. The facility may use EBP at its discretion for resident who do not have a chronic wound, indwelling medical device.10. Staff were trained prior to caring for residents on EBP.11 Signs are posted.12. PPE for EBP's is available outside or inside the resident room.13. Residents, families, and visitors are notified of implementation. Record review of a facility policy titled Infection Control System dated October 2025 indicated .Designated Infection Preventionist.The Director of Nursing (DON) and Assistant Director of Nursing (ADON) must complete an approved Infection Preventionist Course.The ADON will serve as the designated Infection Preventionist for the facility.Antibiotic Stewardship Program.the facility maintains an Antibiotic Stewardship Program in accordance with CMS and CDC standards.Infection Tracking and Surveillance.Care planning.Competencies and Education.Facility assessment.

Based on observation, record review, and interview, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 12 residents reviewed for resident rights. (Resident #60) The facility failed to protect and promote the rights of Resident #60 by standing over the resident while feeding her, being on a personal cell phone while feeding the resident and not speaking to the resident during the meal. This failure could place residents at risk for decreased self-esteem, decreased privacy and decreased quality of life.Record review of an undated face sheet revealed Resident #60 was ana [AGE] year-old female admitted on [DATE] with the diagnoses of major depressive disorder (depressed mood for at least two weeks or more, and a loss of interest or pleasure in everyday activities), protein calorie malnutrition (nutritional status in which reduced availability of nutrients leads to changes in body composition and function) and dementia (a group of symptoms affecting the memory). Record review of a significant change MDS assessment, dated 11/10/2025, revealed Resident #60 had a BIMS of 00 which indicated a severe cognitive impairment. Resident #60 sometimes understood others and sometimes made herself understood. Resident #60 required substantial assistance (extensive) for ADLs such as eating, toileting, transfer, and bathing. Record review of Resident #60's care plan, dated 07/24/2025, revealed Resident #60 had an ADL deficit related to dementia. Resident #60 required one staff assistance with ADL care. During a record review on 12/01/2025 at 10:10 a.m. of the facility Inservice binder from 06/01/2025 to 12/01/2025, no in-service was noted on assisting dependent residents with meals. During an observation on 12/01/2025 from 12:45 p.m. to 12:50 p.m., CNA A stood over Resident #60 while feeding the resident lunch. CNA A was observed looking at and typing on a cellular device the entire observation and failed to speak to Resident #60 while assisting with the meal. During an interview on 12/01/2025 at 1:30 p.m., CNA A stated she was on a personal cellular device for a short time during the lunch meal as she assisted Resident #60. She stated she was standing because there was not a chair in the room to sit in. CNA A stated she had no recollection if she interacted with Resident #60 during lunch. She stated she knew she was supposed to sit down and be on eye level and talk with the resident while feeding her she learned that in CNA class. She stated she also knew the facility had a policy that no cell phone usage should take place in the resident care areas. CNA A stated it could make the residents feel lonesome or ignored with no conversation during mealtime. During an interview on 12/03/2025 at 10:00 a.m., CNA B stated she learned in her training at CNA class to feed residents while sitting at eye level and to engage with the residents while assisting them with all care. She stated it built trust, and you may be the only person that speaks with that resident that day. CNA B stated the facility had a no cell phone in patient care area policy. During an interview on 12/03/2025 at 11:00 a.m., the Regional Nurse stated the expectation for assisting a dependent diner was for the staff to sit and engage with the resident during mealtime to promote comfort and increase the resident's feeling of connection. She was unaware of any training on assisted dining being done at the facility. The Regional Nurse stated mealtimes could be the most important interaction of a dependent resident's day and it was the duty of the staff to help the resident enjoy the experience. She stated cell phone usage was strictly prohibited in resident care areas for HIPAA reasons and resident comfort. During an interview on 12/03/2025 at 1:00 p.m., the Administrator stated that cell phone usage was not acceptable in resident care areas. He stated the staff were trained to take personal calls and messaging outside or in the breakroom during breaktime. The Administrator stated not sitting while assisting the resident to eat could make the resident feel rushed and meals should be enjoyable for the resident. No training had been provided by the facility on proper assisted resident dining, but the CNAs were aware to not have phones in care area. Review of a facility policy titled Dignity, dated 2001, indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.When assisting with care, residents are supported in exercising their rights, For example, residents are: . provided with a dignified dining experience.

Based on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 22 residents reviewed for respiratory care. (Resident #10) The facility failed to properly store Resident #10's oxygen mask while not in use by the resident. This failure could place residents at risk of respiratory complications or respiratory infection. 1. Record review of a face sheet dated 12/04/25 indicated Resident #10 was [AGE] years old and admitted on [DATE] with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide from the blood), tracheostomy status (an opening in the neck to the windpipe, or trachea, through which a tube is inserted to provide an airway), and history of cardiac arrest (is when the heart suddenly stops beating effectively due to electrical problems, cutting off blood flow to the body ). Record review of the MDS dated [DATE] indicated Resident #10 had no speech. The MDS indicated Resident #10 was usually understood and understood others. The MDS indicated a BIMS was not conducted due to the resident being rarely/never understood. The MDS indicated Resident #10 received tracheostomy care and used a ventilator while a resident in the facility. Record review of a care plan last revised on 11/04/25 indicated Resident #10 had altered respiratory status related to tracheostomy status and was at risk for complications related to his trach. The care plan indicated Resident #10 was at an increased risk for secretions, congestion, respiratory infections and infections to the tracheostomy site. There was an intervention to administer nebulizer as ordered. The care plan did not indicate that Resident #10 would take his oxygen nebulizer mask off and lay it on the nightstand. During an observation on 12/01/25 at 12:08 p.m., revealed a trach oxygen nebulizer mask laying directly on the nightstand of Resident #10. The mask was not stored in a bag. A storage bag was not present on the nightstand. During an observation on 12/02/25 at 7:15 a.m., revealed a trach oxygen nebulizer mask laying directly on the nightstand of Resident #10. The mask was not stored in a bag. A storage bag was not present on the nightstand. During an interview on 12/03/25 at 8:33 a.m., LVN G said oxygen mask and equipment when not in use should be stored in a bag. She said Resident #10 did take his mask off and just lay it around. She said she did believe that a storage bag was not present. She said an oxygen mask not being stored in a bag could get bacteria on it and go straight to a resident's lungs. During an interview on 12/03/25 at 9:21 a.m., the Wound Care Nurse said all oxygen supplies were supposed to be bagged when not in use. She said she would have expected Resident #10's mask to have been stored in a bag. She said a mask not being stored in a bag is an infection control issue. During an interview on 12/03/25 at 11:22 a.m., the ADON said oxygen equipment was supposed to be stored at bedside in a respiratory bag and hung on the concentrator or placed in a drawer at bedside. She said she would not have expected Resident #10's mask to have not been left directly on the bedside table. She said if it was contaminated, he could get a respiratory infection. She said it could be lost, and he might be unable to locate the mask if needed. During an interview on 12/03/25 at 1:07 p.m., the Regional Nurse said oxygen supplies not in use should be bagged. If the resident took off the equipment themselves, it should care planned and the resident should be educated on the equipment being bagged. She said oxygen equipment not being bagged was a risk for infection. During an interview on 12/03/25 at 1:21 p.m., the Administrator said oxygen supplies not being used should be bagged. He said equipment not being bagged was not being kept clean. Record review of an Oxygen Administration facility policy last revised 10/2010 did not indicate proper storage of equipment while not in use by a resident.

Based on observation, interview, and record review, the facility failed to ensure residents who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections to the extent possible for 1 of 2 residents reviewed for catheter care. (Resident #81).The facility failed to ensure Resident # 81's securement device was in place to reduce friction and movement at the insertion site on 12/1/2025.This failure could place residents at risk of not receiving care and services needed to address catheter care.Findings included: Record review of Resident #81's face sheet dated 12/2/2025 indicated Resident #81 was a [AGE] year-old, male and readmitted on [DATE] with diagnoses including cerebral infarction (a medical condition characterized by the interruption of blood supply to the brain), atherosclerotic heart disease of native coronary artery with other forms of angina pectoris (characterized by the buildup of plaque in the coronary arteries, leading to narrowed or blocked arteries which can cause (angina) chest pain), essential hypertension (characterized by consistently high blood pressure readings,, typically defined as a systolic pressure of 130 mmHG or higher and/or a diastolic pressure on 80 mmHg or higher), and benign prostatic hyperplasia with lower urinary tract symptoms (an enlarged prostate can cause symptoms that can block the flow of urine out of the bladder), and chronic cystitis with hematuria (a long-lasting inflammation of the bladder that can cause symptoms such as pelvic pain, frequent urination and urgency). Record review of Resident #81's care plan initiated 5/1/2024 indicated Resident #81 had an indwelling foley catheter: Atonal bladder (a condition where the bladder muscles cannot contract fully), neurogenic bladder (a condition where nerve damage affects bladder control leading to issues such as urinary incontinence or retention), benign prostatic hypertrophy obstructive uropathy and retention of urine (a common condition that can lead to urinary retention due to the obstruction caused by the enlarge prostate). Intervention included to change catheter every month and PRN for failure to drain, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks and maintain the drainage bag off the floor, enhanced barrier precautions; post EBP sign in room, gown, gloves to be worn during high-contact resident care with indwelling medical device, monitor and document intake and output as per facility policy, monitor/document for pain/discomfort due to catheter, and monitor/record/report to MD for signs and symptoms of UTI such as pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status and change in behavior, and eating patterns. Record review of Resident #81's care plan initiated on 5/6/2024 indicated Resident #81 had behavioral problems related to fascination with foley catheter tubing and privacy bags. Resident #81 would sit on tubing, remove privacy bag, and refuses to reposition, wraps tubing around body, thinks privacy bag was a belt, lifts bag above bladder level at times, and empties foley catheter at times. Interventions included: administer medications as ordered. Monitor and document for side effects and effectiveness, anticipate and meet the resident's needs, and evaluate for leg bag if appropriate.Record review of a quarterly MDS dated [DATE] indicated Resident #81 had a BIMS score of 6 indicating he had severely cognitive impairment. Resident #81 was able to make self-understood and understood others. The MDS indicated Resident #81 had an indwelling catheter and required assistance for personal hygiene. During an observation on 12/1/2025 at 8:18 AM, Resident #81 was observed lying in bed with wheelchair at bedside. Observed Resident #81 wearing brief with blood located near the insertion site and 700 cc of red blood in urine bag located on the floor without a privacy bag and no securement device anchoring the catheter tubing. Resident was withdrawn and did not communicate during observation. During an interview and observation on 12/1/2025 at 8:25 AM, LVN L said Resident #81's catheter was changed on Saturday. She said he had blood in his catheter this morning. LVN L said Resident #81 pulls on his catheter. LVN L said Resident #81 had an appointment today with a Urologist. Resident #81 had an appointment on 12/1/2025 with Nephrologist (a Physician who diagnose and manage various kidney-related conditions). During an interview on 12/1/2025 at 3:15 PM. LVN L said Resident #81's catheter was irrigated, and Resident #81 was referred to a Urologist in another town. She said the facility was waiting for a return call to schedule. During an interview on 12/1/2025 at 3:22 PM, the ADON said Resident #81 was seen by his Nephrologist today and he wanted the facility to continue to monitor. The ADON scanned the note into the computer system. During an observation and interview on 12/2/2025 at 9:18 AM, Resident #81 was attempting to wheel himself down the hall and needed assistance. He was observed to have yellow urine in part of the tubing and blood-tinged urine in the catheter bag attached to the wheelchair and covered with a privacy bag. Unable to determine if a securement device was anchored and secured. The ADON came to assist Resident #81 and said she the Physician had ordered labs yesterday and she was waiting for the results. During an interview on 12/3/2025 at 9:34 AM, CNA K said she provided catheter care for residents with catheters. CNA K said she was not familiar with securement devices on catheter tubing. She said she had seen them. CNA K said she did not mess with the securement devices, and the nurses were responsible for the catheters. CNA K said it could cause infection if a securement device was on the catheter. During an interview on 12/3/2025 at 10:53 AM, LVN G said residents with catheters should have a securement device on the catheter. She said it was important, so the catheter does not pull, or the resident does not pull it out. LVN G said the securement device was changed monthly and as needed. She said it could cause the resident pain and infection if the catheter slides back and forth. LVN G said the nurse was responsible for ensuring the securement device was on the resident. LVN G said she assessed it when she makes her rounds. LVN G said Resident #81 does not like the securement device or privacy bag. LVN G said it would be care planned if he refused the securement device. During an interview on 12/3/2025 at 11:05 AM, the ADON said residents with catheters should have a securement device on the catheter. She said the securement device was to prevent the catheter from being pulled out and potentially causing injury. The ADON said Resident #81 should have a securement device. The ADON said she was going to get with the MDS nurse and have her care plan for his refusal and messing with the catheter. The ADON said the nurses were responsible for ensuring privacy cover and securement device was on the catheter. During an interview on 12/3/2025 at 1:20 PM, the Regional Nurse said she expected the staff to make sure the resident had a securement device and privacy bag on the foley catheter. The Regional Nurse said the charge nurses were responsible for ensuring the catheter was secure and the catheter bag was off the floor. The Regional Nurse said it should be care planned for noncompliance. The Regional Nurse said Resident #81 could get an infection due to the catheter not being secure and it could cause trauma related to urethra trauma. During an interview on 12/3/2025 at 1:35 PM, the ADM said the securement device should be on a resident with a catheter bag and the privacy bag should be covering the catheter bag. The ADM said the nurse was responsible for ensuring the privacy bag and securement device were in place. He said not having the securement device in place could cause infection of the bladder. Record review of the facility's policy dated July 2024 titled Catheter Care, Urinary, indicated .purpose of this procedure is to prevent catheter-associated urinary tract infections. Changing catheters.Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. Catheter tubing should be strapped to the resident's inner thigh. Complications.Observe resident for complications associated with urinary catheters.

Based on interviews and reviews, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 6 residents (Resident #11) reviewed for (DRR) Drug Regimen Review. The facility failed to complete a psychotropic consent form for Resident #11 after the pharmacist recommended the form was needed on 11/10/2025 for Haldol (antipsychotic mediation) and Zyprexa (antipsychotic medication). This failure could place residents at risk residents of not having a drug regiment that is appropriate for their needs.Record review of an undated face sheet dated revealed Resident #11 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of schizophreniform disorder (a psychotic disorder characterized by symptoms similar to schizophrenia, such as delusions, hallucinations, and disorganized speech, but its duration is shorter, lasting from one to six months) psychotic disorder (a severe mental health condition characterized by a loss of contact with reality, resulting in symptoms like hallucinations, delusions, and disorganized thinking and speech) and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the order summary report on 12/3/2025 at 9:00 a.m., dated 12/01/2025, indicated Resident #11 was prescribed Haldol 1 mg three times daily and Zyprexa 5mg twice daily since 11/21/2025. Record review of the quarterly MDS assessment on 12/3/2025 at 9:15 a.m., dated 09/12/2025, revealed Resident #11 had a BIMS of 13, which indicated minimal cognitive impairment. The MDS revealed Resident #11 used antipsychotic medications and required partial to moderate assistance with ADL care. Record review of the MARs dated November 2025 and December 2025, indicated Resident #11 received Haldol three times daily from 11/21/2025 to 12/02/2025. The MARs also indicated, Resident #11 received Zyprexa 5mg twice daily from 11/21/2025 to 12/02/2025. Record review of the comprehensive care plan, revised on 09/16/2025, revealed Resident #11 used antipsychotic medications for the treatment of schizophreniform disorder. Record review of the Pharmacist Consultant Medication Regimen Review dated 11/10/2025 revealed the licensed pharmacist recommended consents should be obtained and added to chart for the following medications: Haldol and Zyprexa for Resident #11. The pharmacist also recommended adding side effect monitoring and behavior monitoring for Resident #11's antipsychotic medication usage. During an interview on 12/03/2025 at 11:50 a.m., the DON stated the Pharmacy Consultant recommendations for Resident #11 should have been reviewed but it was not, if it had been reviewed, she would initial on the report when recommendations had been followed up. The DON stated the nurse who received the order was responsible for ensuring the consents are signed and completed prior to the first dose of medication administration. The DON stated she monitors by reviewing the orders to ensure consents were obtained in a timely manner during her daily clinical meeting with the ADON, Administrator, and the 6a-2p charge nurses. The DON was unable to give an explanation why the pharmacy recommendation was not completed. The DON stated not reviewing pharmacy consultations and documenting they had been reviewed and completed could lead to something the patient needed being missed. During an interview on 12/03/2025 at 1:52 p.m., the Administrator stated he expected all pharmacist recommendations to be reviewed with the physician and followed. He stated he expected psychotropic consent forms to be obtained prior to administering psychotropic medications, side effect and behavior monitoring to be done per pharmacist recommendation. The Administrator stated nursing management was responsible for monitoring psychotropic consent forms and that side effects and behaviors were monitored. The Administrator stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications to ensure the residents were informed of the risks and benefits and provided informed consent. The Administrator stated the failure was unnecessary medication maybe given. Record review of the facility's Psychotropic/Psychoactive Medication Management policy revised 10/2022 revealed . psychotropic medications are used only when appropriate and at the lowest possible dose to enhance the residents' quality of life, maximize functional ability or promote overall well-being. Record review of the facility's Pharmacy Services Overview policy revised 04/2025 revealed . 2. The facility shall contract with a licensed consultant pharmacist to help obtain and maintain timely and appropriate pharmacy services that support residents' needs, are consistent with current standards of practice, and meet state and federal requirements.

Based on interview and record review, the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for accuracy of assessments. (Resident #8) The facility failed to accurately document restraint usage for Resident #8. This failure could place residents at risk of not receiving needed care and services. Record review of an undated face sheet revealed Resident #8 was a 100- year-old- female, admitted on [DATE] with the diagnoses of Alzheimer's disease (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), anemia (a condition in which the body does not have enough healthy red blood cells), and malnutrition (a nutritional status in which reduced availability of nutrients leads to changes in body composition and function). Record review of a quarterly MDS, dated [DATE], for Resident #8 revealed a BIMS of 05, which indicated a severe cognitive impairment. The MDS also revealed Resident #8 required substantial assistance with bed mobility, eating, transferring, and toileting. The MDS revealed Resident #8 required a restraint less than daily. Record review of December 2025 consolidated physician orders revealed no order for a restraint for Resident #8. During an interview on 12/02/2025 at 10:00 a.m., MDS Nurse E revealed Resident #8 should not have been coded as having a restraint less than daily on the MDS. MDS Nurse E stated there were no restraints in the facility and this was a miscoding. MDS Nurse E stated miscoding the MDS could lead to wrong information reported on the Quality Measures and potentially wrong information care planned for the resident, which could confuse the staff caring for the resident. During an interview on 12/03/2025 at 11:15 a.m., the Regional Nurse stated it was the responsibility of the MDS nurse to ensure accurate MDS's were produced and transmitted to CMS. The DON stated there was currently no system check in place to audit the MDS accuracy but ultimately the DON or Regional Nurse signed the MDS for completion and the MDS nurses signed it for accuracy. During an interview on 12/03/2025 at 2:00 p.m., the Administrator stated it was the responsibility of the MDS Nurse to produce accurate MDSs and care plans. The Administrator stated accuracy was important for revenue as well as to ensure the facility was reporting the correct information to CMS on the quality measures. During a record review of the facility's undated policy titled Minimum Data Set Policy for MDS assessment Data Accuracy, revealed the purpose of the MDS policy was to ensure each resident received an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being. The assessment should accurately reflect the resident's status.

Based on observation, interview and record review the facility failed to ensure the PICC line site was maintained consistent with professional standards of practice for 1 of 1 residents (Resident #83) reviewed for central venous lines (a thin, flexible tube that's inserted into a large vein to provide access to the circulatory system). The facility failed to change a PICC line (a type of central venous line) dressing, consistent with physician's orders for Resident #83. This failure could place residents at risk of a systemic infection that could lead to serious illness and/or death. Record review of a face sheet dated 12/02/25 revealed Resident #83 was a [AGE] year-old male and was re-admitted on [DATE] with diagnoses including sepsis due to Escherichia Coli (a life-threatening condition caused by the body's extreme response to an E. coli (a type of bacteria) infection), muscle wasting, and lack of coordination. Record review of a progress note dated 11/21/25 at 10:11 p.m. indicated Resident #83 had returned to the facility from the hospital. Record review of a progress note indicated Resident #83 had new orders for intravenous antibiotics. Record review of a physician's order for Resident #83 dated 11/23/25 indicated an order for a dressing change to PICC (a type of central venous line) site every 7 days and as needed. The order type was listed as a wound (WAR - wound administration record). The order was entered by LVN G. Record review of an annual MDS dated [DATE] revealed Resident #83's speech was unclear. The MDS revealed a BIMS score of 12, indicating moderate cognitive impairment. The MDS indicated Resident #83 was dependent on staff for ADLs. Record review of a care plan last revised on 11/21/25 revealed Resident #83 had received antibiotic therapy through a PICC line in 07/2025. The care plan did not indicate the resident had a PICC line or had received IV (intravenous) antibiotics beginning 11/21/25. Record review of Resident #83's electronic medical record from 11/21/25 - 12/02/25 did not indicate documentation of a central venous line dressing change. The Medication Administration Record, Treatment Administration Record, Nurse Medication Record, and the Wound Administration Record were all reviewed. During an observation on 12/02/25 at 11:45 a.m., Resident #83 was in bed. There was a PICC Line with a transparent dressing to his left upper arm. The dressing was clean, dry and intact. The dressing was dated 11/21/25. There were no signs of infection. During an interview on 12/03/25 at 8:33 a.m., LVN G said Resident #83 was re-admitted to the facility on [DATE]. She said she was off that day. She said when he was re-admitted he did have the PICC line in place. She said she did remember putting the order in for a PICC line dressing change for every 7 days for his PICC line. She said she tried to follow up on PICC lines and catheters on newly admitted or re-admitted residents. She said the policy was for PICC line dressings to be changed every 7 days. She said she did not know why the order did not pull over for documentation. She said maybe she selected the wrong category. She said she did administer his medications while he was getting them. She said she did assess the date on the dressing. She said she did not know why the dressing had not been changed on 11/28/25. She said the wound care nurse usually did the PICC line dressing changes. She said when she entered the order, she selected wound care documentation and maybe the order should have been placed under the treatment administration record. She said then the order would have populated for the wound care nurse. She said a PICC line dressing not being changed could lead to infection or sepsis. During an interview on 12/03/25 at 9:21 a.m., the Wound Care Nurse said on 12/02/25 there was an order placed to pull the PICC line from Resident #83's left upper arm. She said she removed the PICC line on 12/02/25. She said pressure was held and there were no signs of infection. She said when she pulled the PICC line she did notice the date on the dressing was 11/21/25 . She said any RN could do the dressing changes on a PICC line. She said the dressings should be changed every week. She said the order never crossed over to her treatment administration record. She said she never knew that the dressing change needed to be done. She said she never administered any medications through the PICC line. She said any nurse giving a medication though the PICC line should have assessed the line and dressing. She said she would have expected it to have been changed within the 7 days of 11/21/25. She said a dressing not being changed timely could lead to infection. She said dressings can become old and pull up from the skin. During an interview on 12/03/25 at 11:22 a.m., the ADON said Resident #83 was re-admitted on [DATE] with the PICC line in place. She said a PICC line dressing should be changed every 7 days and as needed. She said the order was put in and it was put into a medication administration record that was being phased out, and it did not populate on the treatment administration record for the Wound Care Nurse. She said she would have expected nurses administering medications to have checked the date on the dressing and changed it as needed. She said a PICC line not being changed could lead to infection and possible sepsis. During an interview on 12/03/25 at 1:07 p.m., Regional Nurse said PICC line dressings should be changed every 7 days. She said the order went onto the wrong treatment administration record and it did not trigger to the Wound Care Nurse's treatment administration record. She said the doctor did order to have it pulled yesterday (12/02/25). She said she would have expected nurses to have assessed the PICC line dress when administering medications and someone should have caught that the dressing had not been changed. She said a PICC line dressing not being changed at least every 7 days increased the risk of infection. During an interview on 12/03/25 at 1:21 p.m., the Administrator said staff should follow the doctor's orders for PICC line dressing changes. He said a PICC line dressing not being changed could lead to infection. During an interview on 12/03/25 at 4:35 p.m., the Regional Nurse said she had been unable to find a facility policy for PICC line dressing changes. A policy was not received prior to exit. The website https://medlineplus.gov/ency/patientinstructions/000156.htm accessed on 12/04/25 indicated, . Central venous catheter - dressing change. Dressings are special bandages that block germs and keep your catheter site dry and clean. You'll need to change your dressing often, so that germs don't get into your catheter and make you sick. You should change the dressing about once a week. You will need to change it sooner if it becomes loose or gets wet or dirty.

Based on observation, interview, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the option he or she prefers for 1 of 6 residents reviewed for the right to be informed. (Resident #11) 1. The facility failed to ensure Resident #11 had a signed psychotropic consent form for Haldol and Zyprexa (antipsychotic medications). 2. The facility did not ensure the need for, and benefits of, the proposed treatment with antipsychotic or neuroleptic medication was filled out on the HHSC Form 1012 Consent for Antipsychotic or Neuroleptic Medication.These failures could place residents at risk for treatment or services provided without their informed consent Record review of an undated face sheet dated revealed Resident #11 was an [AGE] year-old male admitted on [DATE] with diagnoses of schizophreniform disorder (a psychotic disorder characterized by symptoms similar to schizophrenia, such as delusions, hallucinations, and disorganized speech, but its duration is shorter, lasting from one to six months) psychotic disorder (a severe mental health condition characterized by a loss of contact with reality, resulting in symptoms like hallucinations, delusions, and disorganized thinking and speech) and chronic atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat). Record review of the quarterly MDS assessment, dated 09/12/2025, revealed Resident #11 had a BIMS of 13, which indicated cognitively intact. The MDS revealed Resident #11 used antipsychotic medications and required partial to moderate assistance with ADL care. Record review of the comprehensive care plan, dated 09/16/2025, revealed Resident #11 used antipsychotic medications for the treatment of schizophreniform disorder. Record review of the order summary report, dated 12/03/2025, revealed Resident #11 had an order, which started on 11/21/2025, for Haldol 1mg three times daily and Zyprexa 5mg twice daily. Record review of the MAR, dated 12/03/2025, revealed Resident #11 received Haldol 1 mg and Zyprexa 5mg as ordered by the physician. Record review of the electronic medical record for Resident #11, accessed on 12/03/2025 at 10:00 a.m., revealed no consent forms for Haldol or Zyprexa. During an observation and interview on 12/03/2025 at 9:34 a.m., Resident #11 was sitting in his wheelchair in his room, clothing appeared neat and clean. Resident #11 was pleasant during interview but was not able to remember the medications he was taking. He stated he was unaware he was on antipsychotic medications and was unaware of the side effects. He stated he had no behavior issues that he was aware of. During an interview on 12/03/2025 at 11:10 a.m., Resident # 11's family member stated they never signed consent or gave permission for the medication because Resident #11 usually took care of his own business. During an interview on 12/03/2025 at 11:16 a.m., LVN G stated she was responsible for completing the psychotropic consent forms for Resident #11 because she received the order changes, but she got busy and forgot to have the consent signed. LVN G stated an informed consent form should have been obtained for an antipsychotic medication prior to the medication being administered. LVN G stated it was important to ensure psychotropic medication consent forms were obtained prior to administering the medications so the resident and family knew the risks and benefits of the medication. LVN G stated the failure of not getting a consent prior to administration of the medication could cause unwanted side effects to the resident and was against the resident's right. During an interview on 12/03/2025 at 11:20 a.m., the DON stated the nurses were responsible for ensuring psychotropic consent forms were obtained prior to administering the medications. The DON stated consent form should have been obtained for Resident #11's Haldol and Zyprexa. The DON stated it was important to ensure consent forms were completed prior to administering medications so that residents and their family were aware of the medication, side effects, risks, and benefits. The DON stated the failure was the resident may not get the medication they need. The DON stated she would monitor by medication review. During an interview on 12/03/2025 at 1:52 p.m., the Administrator stated he expected psychotropic consent forms to be obtained prior to administering psychotropic medications. The Administrator stated nursing management was responsible for monitoring psychotropic consent forms. The Administrator stated it was important to ensure psychotropic consent forms were obtained prior to administering the medications to ensure the residents were informed of the risks and benefits and provided informed consent. The Administrator stated the failure was unnecessary medication may be given. Record review of the Psychotropic Medication Review policy, dated May 2025, did not address psychotropic consent forms.

Based on interviews and record review, the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 22 residents (Resident #55) reviewed for baseline care plans. The facility failed to ensure Resident #55's baseline care plan was completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome. The findings included: Record review of the face sheet, dated 12/03/25, reflected Resident #55 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of extradural and subdural abscess (buildup of pus from an infection located in the brain), acute on chronic heart failure (chronic, progressive disease in which the heart muscle is unable to pump enough blood to oxygenate the body), and COPD (chronic lung condition in which the lungs are damaged). Record review of the admission MDS assessment, dated 11/25/25, reflected Resident #55 had unclear speech, was sometimes understood by others, and was able to understand others. Resident #55 had a BIMS score of 9, which indicated moderately impaired cognition. Resident #55 had no behaviors or refusal of care. Record review of Resident #55's baseline care plan, completed on 11/17/25. The baseline care plan should have been completed by 11/16/25. During an interview on 12/03/25 beginning at 3:12 PM, LVN O stated the admitting nurses were responsible for completing the baseline care plan. LVN O said she was unsure of the timeframes for completing the baseline care plans. LVN O said Resident #55 was admitted to the facility on her shift, but she was unsure why his baseline care plan was not completed until 11/17/25. LVN O stated the baseline care plan reflected the care and services needed by the residents when they were admitted to the facility. She said it was important to ensure the baseline care plan was completed within the required timeframes to ensure communication of the care and services needed by the residents from the facility staff. During an interview on 12/03/25 beginning at 3:20 PM, the Regional Nurse stated she was the acting DON until a new one was hired. The Regional Nurse stated baseline care plans should have been completed within 48 hours of admission. She stated the DON was responsible for ensuring the baseline care plans were completed. The Regional Nurse stated she was unsure why Resident #55's care plan was completed late. She said it was important to ensure baseline care plans were completed within the required timeframes to capture the care each resident needs. During an interview on 12/03/25 beginning at 3:46 PM, the Interim Administrator stated he expected the baseline care plans to have been completed within 48 hours of admitting to the facility or as quickly as possible after 48 hours. The Interim Administrator stated the nursing management was responsible for monitoring to ensure baseline care plans were completed timely. He said it was important to ensure baseline care plans were completed within the required timeframes because it was used to deliver care to the residents. Record review of the Care Plans - Baseline policy, revised March 2022, reflected, A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Based on observation, interviews 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 reviewed for kitchen sanitation in that: 1. Dietary Manager not properly securing facial hair. 2. Particles on top of dishwasher. 3. Grease buildup on the left side of gas stove and grease [NAME]. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness. The findings were: 1. During an observation on 9/16/2024 at 8:55 AM, the dietary manager was not wearing proper facial covering upon entry into the kitchen. During an observation on 9/17/2024 at 8:19 AM, the dietary manager was not wearing facial covering. During an observation and interview on 9/18/2024 at 9:50 AM, Dietary Aide A said everyone should be wearing hair covering while entering the kitchen. She said males should have their facial hair covered and no hair should be sticking out of the hair net. Dietary Aide A said the kitchen staff were to secure hair with hairnets as soon as walking in the kitchen. Dietary Aide A said a resident could negatively be impacted if they had hair in their food. During an interview on 9/18/2024 at 9:52 AM, Dietary [NAME] B said everyone should be wearing hairnets as soon as they enter the kitchen and hair should be tucked in properly. She said males should be wearing facial restraints. Dietary [NAME] B said hair could fall out on a resident's food and make them sick. Dietary [NAME] B said the Dietary Manager was responsible for ensuring everyone was wearing hair nets correctly. Dietary [NAME] B said a resident could get upset if they found hair in their food. During an interview on 9/18/2024 at 10:05 AM, the Dietary Manager said everyone should be wearing hairnets and men should be wearing facial covering. The Dietary Manager said mustache were supposed to be covered. He said the current facial coverings provided by the facility fall off his face. He said he had notified the previous Dietary Manager and the ADM that the facial restraint provided, did not properly fit him. The Dietary Manager said the previous Dietary Manager and ADM advised him to look at the supplies on his computer and find a different covering that fit properly. The Dietary Manager said no hair should be sticking out of hair restraints or at the base of the neck. The Dietary Manager said hair could contaminate the food and he was responsible for ensuring all staff were wearing their hairnets properly. During an interview on 9/18/2024 at 2:53 PM, the DON said the ADM was over the Dietary Manager. The DON said she expected the kitchen staff to wear hair nets properly. She said if a male kitchen staff had long or short beard, they should be wearing a facial covering. The DON said she was not sure if the facial covering should be on only when handling food or while cleaning the kitchen. During an interview on 9/18/2024 at 3:54 PM, the ADM said all kitchen staff should be wearing hair nets and facial covering for the male staff if they have facial hair, beards, and mustache. The ADM said the hair restraints should be secured while in the kitchen. He said the Dietary Manager was responsible for ensuring kitchen staff were properly hair nets and facial restraints. The ADM said not securing the hair could contaminate the food with loose hair. 2. During an observation and interview on 9/18/2024 at 9:50 AM, Dietary [NAME] A said the cook was responsible for the oven and [NAME] and she was not sure how often it was supposed to be cleaned. During interview, observed the top of dishwasher covered with food particles. The Dietary Aide A said she cleans the dishwasher everyday but there was not a checklist she marked completed. Dietary Aide A said the top of the dishwasher did not appear clean and she was not sure when it was last cleaned. She said the food particles on the top of dishwasher could blow on the clean dishes and could make a resident sick. During an observation and interview on 9/18/2024 at 9:52 AM, Dietary [NAME] B said the kitchen staff are supposed to clean the oven and [NAME]. Dietary [NAME] B said the Dietary Manager cleaned the [NAME]. Dietary [NAME] B said there was a checklist on a clip board in the kitchen of daily duties. Dietary [NAME] B said grease build up on the oven could spark a fire and said it would not cause any harm to resident's because they were not in the kitchen. Dietary [NAME] B said she was not sure if a foodborne illness could happen if grease or oil was not properly cleaned out. She said she thought it could make someone sick. Dietary [NAME] B said the oven and stove were only serviced when there was something wrong with it. Dietary [NAME] B provided the kitchen cleaning schedule for September titled Magnolia Place Dietary Department indicated cleaning schedule not initialed and black mark through the Dietary Aide Side, Sunday through Saturday schedule. During an interview on 9/18/2024 at 10:05 AM, the Dietary Manager said he was responsible for the cleaning of the [NAME] every Friday. He said he does not document the cleaning and does not have a checklist for the [NAME]. The Dietary Manager said the cook was responsible for cleaning the oven and the night cook was the one who should be cleaning oven. The Dietary Manager said there was a cleaning schedule hanging on the clipboard in the kitchen. He said the kitchen staff should be checking the checklist before leaving for the evening. The Dietary Manager said he does go behind the kitchen staff to ensure the cleaning was completed. The Dietary Manager said he was aware of the food particles on the dishwasher and said he was not sure how it keeps getting buildup of particles. The Dietary Manager said the food particles on top of the dishwasher and on the [NAME] could contaminate the clean dishes or food with potential to make a resident sick. During an interview on 9/18/2024 at 2:53 PM, the DON said kitchen staff are responsible for keeping the oven, [NAME] and dishwasher clean. She said she was not sure about the kitchen cleaning schedule. The DON said she would expect there to be a schedule in place and a checklist to be initialed if the cleaning was completed. The DON said she would expect the Dietary Manager to go behind the kitchen staff the cleaning was completed. The DON said she could not speak to if grease buildup on the side of the oven and [NAME] would cause a fire. During an interview on 9/18/2024 at 3:54 PM, the ADM said everyone in the kitchen was responsible for cleaning the oven, [NAME] and dishwasher. The ADM said there should be a checklist indicating what needs to be cleaned and should be completed daily. The ADM said he felt just checking a list was fine for now but said he would visit initialing the checklist and discuss with the Dietary Manager. During an interview on 9/19/2024 at 11:32 AM, the Dietician said she was just notified State was in the building. The Dietician said she would provide the cleaning schedule and facility policies for cleaning schedule and employee sanitation. During record review of facility kitchen checklist dated September titled Magnolia Place Dietary Department indicated cleaning schedule not initialed and black mark through the Dietary Aide Side, Sunday - Saturday schedule. Prep Workstation checklist indicated .clean microwave after each meal service, keep overhead shelf cleaned and polished weekly, keep counter clean from buildup and polish weekly, clean crumbs from toaster after each use, keep lower shelves clean from debris, spillage, and polish weekly, and keep drawers organized and free from dirt and grim. No observed initials or dates of completion from dietary staff or manager. During record review of the facility policy dated October 2018 titled Cleaning Schedule indicated the facility will maintain a cleaning schedule prepared by the Nutrition and Foodservice Manager and followed by employees as assigned in order to ensure the kitchen is clean and free of hazards .Procedure: 1. The Nutrition and Foodservices Manager will develop a cleaning schedule for daily, weekly and monthly cleaning .2. Cleaning task will be assigned to positions and included in the job descriptions. 3. The cleaning list will be posted weekly and initialed off and dated by each employee upon completion of the task. The Nutrition and Foodservice Manager or designed will verify that the tasks were completed as assigned. During record review of facility policy dated October 1 , 2018 titled Employee Sanitation indicated .Policy .The Nutrition and Foodservice employees of the facility will practice good sanitation practices in accordance with the state and US food Codes in order to minimize the risk of infection and food borne illness . Procedure .Do not allow employees who have communicable diseases, who are carriers of communicable diseases, who have boils, infected wounds, sores or acute respiratory infection to work in any area of the kitchen .2. If the Nutrition and Foodservice Manager suspects that an employee has contracted a communicable disease .3. Employee Cleanliness Requirements .a. All employees must wear clean outer clothing .b. Hairnets, headbands, caps, beard coverings or other effective hair restraints must be worn to keep hair from food and food-contact surfaces .

Based on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 3 of 22 residents (Resident #8, Resident #48, and Resident #190) reviewed for respiratory care. 1. The facility failed to change the oxygen tubing for Resident #8. 2. The facility failed to ensure Resident #48's nasal cannula humidification bottle (aids in preventing a patient's airways from becoming dry) had water in it. 3. The facility failed to ensure LVN Q performed Resident #190's tracheostomy care using aseptic technique per the facility's policy. 4. The facility failed to ensure LVN Q performed Resident #190's tracheostomy care and cleaning per the facility's policy. 5. The facility failed to ensure LVN Q used the prescribed solution to clean Resident #190's tracheostomy site. These failures could place residents at risk for of respiratory infections. Findings included: 1. Record review of Resident #8's face sheet, dated 3/16/24 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease (a common lung disease that makes it difficult to breathe), Osteoporosis (a bone disease that causes bones to become brittle and break easily), Anxiety Disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities.) Record review of Resident #8's quarterly MDS assessment, dated 08/28/24, revealed Resident #8 had a BIMS of 99, which indicated she was unable to complete the BIMS test. Shows that resident #8 requires extensive assistance with ADLs. Record review of an order for Resident #8, dated 3/18/23, shows that staff were to, Change O2 tubing/water every week on Friday and PRN .Every night shift every Friday related to pneumonia. During an interview on 9/18/24 at 3:15 p.m., the DON said that it was the responsibility of facility nurses to ensure that residents oxygen tubing was changed per orders and labeled with the new date. She stated that residents could be placed at risk for respiratory infections if their oxygen tubing was not changed properly. During an interview on 9/18/24 at 3:30 p.m., the ADM said that it was the responsibility of nursing staff to change the oxygen tubing for oxygen concentrators as it was ordered. He said that residents could be placed at risk for respiratory infections if they were not supplied with clean oxygen tubing. 2. Record review of Resident #48's face sheet dated 09/23/24 indicated Resident #48 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including congestive heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), cardiomegaly (is when your heart is abnormally thick or overly stretched, becoming larger than usual, with difficulty pumping blood), and atrial fibrillation (is an irregular heart rhythm that begins in your heart's upper chambers (atria)). Record review of Resident #48's quarterly MDS assessment dated [DATE] indicated Resident #48 was usually understood and usually understood others. Resident #48's BIMS score was 06 which indicated severe cognitive impairment. Resident #48 required moderate assistance for toilet hygiene, shower/bathe self, dressing, and personal hygiene, and supervision for oral hygiene. Resident #48 received oxygen therapy. Record review of Resident #48's care plan dated 07/02/24 indicated Resident #48 had oxygen therapy related to congestive heart failure and ineffective gas exchange. Intervention included oxygen settings: the resident has oxygen therapy via nasal cannula at 2 liters continuously, humidified. Encourage resident to keep nasal cannula in [NAME] for improved air exchange. During an observation and interview on 09/16/24 at 9:19 a.m., Resident #48 was sitting in her wheelchair beside her bed. Resident #48 was on 3.5 liter via a nasal cannula. Resident #48's humidification bottle was dated 09/07/24 and without water. Resident #48 said she did not know how long there had been no water in the bottle. Resident #48 said she thought her nose felt okay. 3. Record review of Resident #190's face sheet dated 09/16/24 indicated Resident #190 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses including aneurysm of the ascending aorta (s a bulging, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning greater than 50% of the vessel's normal diameter (width)), without rupture, presence of heart valve replacement, chronic obstructive pulmonary disease (is a common lung disease causing restricted airflow and breathing problems), encounter for attention to tracheostomy (is a procedure to help air and oxygen reach the lungs by creating an opening into the trachea (windpipe) from outside the neck), and Type 2 diabetes (is a condition that happens because of a problem in the way the body regulates and uses sugar as a fuel). Record review of Resident #190's order summary report dated 09/18/24 indicated cleanse around tracheostomy daily or as needed using sterile water and prepared solution that is provided in trach care, one time day. Start date 09/05/24. Record review of Resident #190's order summary report dated 09/18/24 indicated trach care every shift and as needed. Start date 09/10/24. Record review of Resident #190's admission MDS assessment dated [DATE] indicated Resident #190 was understood and understood others. Resident #190's BIMS score was 15 which indicated intact cognition. Resident #190's admission performance requirement was partial assistance for lower body dressing, shower/bathe self, and toilet hygiene, supervision assistance for upper body dressing, and set-up assistance for oral hygiene. Record review of Resident #190's undated baseline care plan indicated oxygen therapy and tracheostomy care. Resident #190's comprehensive care plan not due yet. During an observation and interview on 09/17/24 at 11:30 a.m., LVN Q performed tracheostomy care of Resident #190. Resident #190 sat in his wheelchair for the procedure. LVN Q washed her hands then placed on gloves. LVN Q opened the sterile trach kit with her gloved hands. LVN Q reached into the trach kit with a gloved hand and moved the sterile drape and pipe cleaners off to the side of the kit. LVN Q squeezed 4 saline bullets into the trach kit and moistened the gauze. LVN Q removed the gauze from under Resident #190 tracheostomy site. LVN Q removed gloves then washed her hands. LVN Q grabbed sterile gloves out of the trach kit and placed them on. LVN Q said the procedure was a clean procedure not sterile procedure in the nursing home. LVN Q grabbed the sterile drape and placed it on Resident #190's chest. The sterile drape slid down Resident #190's chest several times until LVN Q tucked the drape in Resident #190s shirt. The sterile drape was not under the trach site. LVN Q grabbed a long-tipped cotton applicator and moistened with normal saline then cleaned the inside of the tracheostomy hub (is the part that protrudes from the patient's neck) x2. Resident #190 excessively coughed both times. LVN Q then bent a pipe cleaner in half and cleaned inside the tracheostomy hub. Resident #190 excessively coughed during cleaning. LVN Q took a moistened 4x4 gauze and slide the gauze underneath the ride side of the tracheostomy flange (is the part of the tracheostomy tube that extends from the outer part of the tracheostomy tube and has holes to attach the tracheostomy tube tie) then a new 4x4 gauze underneath the left side. Resident #190 excessively coughed both times. Resident #190 then coughed out phlegm from his tracheostomy. LVN Q then bent another pipe cleaner in half and removed excess phlegm from Resident #190's tracheostomy hub. LVN Q then placed a new 4x4 split gauze around Resident #190's trach site. LVN Q then removed Resident #190's Velcro trach tube holder (is used to hold a tracheostomy tube in place. The collar connects to the tracheostomy plates, which work to stabilize the tube.) and applied a new one without another staff member. LVN Q did not remove the tracheostomy cannula and clean it with hydrogen peroxide and sterile water. LVN Q did not clean around the trach site with hydrogen peroxide and sterile water. During an interview on 09/18/24 at 1:11 p.m., LVN Q said the facility did an in-service on trach care before Resident #190 was admitted . She said trach care was a clean procedure in the nursing home setting. She said she did not know the physician order said to clean with sterile water and prepared solution in the trach kit. She said she always cleaned Resident #190's trach site with normal saline. She said she always cleaned the trach site and cannula with it in Resident #190. She said she did not know she was supposed to take the trach cannula out with trach care. She said the trach kit did have sterile gloves in it. She said the trach care kit became contaminated when she used the regular glove to move items. She said it was important to perform aseptic trach care to keep the resident infection free. She said when trach care was not performed correctly it place resident at risk for infection. She said she did not know the trach policy stated two people was required for changing the trach tube holder. She said two people were probably needed so one nurse could hold the trach in place, while the other staff member changed the holder. She said night shift was responsible for changing the respiratory equipment every 7 days. She said nasal cannulas got gross and nasty. She said when nasal cannulas were not changed every 7 days, it could cause infections. She said all nursing staff were responsible for keeping water in the humidification bottles. She said if water was not in the humidification bottle it could cause resident to have a dry nose. She said a dry nose could cause nose bleeds. She said she did not notice Resident #48's humidification bottle was dry on 09/16/24. During an interview on 09/18/24 at 1:44 p.m., LVN R said the nursing staff on 10pm-6am shift changed the oxygen tubing. She said the night shift nursing staff changed it weekly. She said it was important to change the oxygen tubing weekly for infection control. She said when nasal cannulas were not changed weekly it placed resident at risk for infection and the need for antibiotics. She said all staff should make sure water was in the humidification bottles. She said night shift nurse should place a new humidification bottle when the oxygen tubing was changed. She said using a nasal cannula without humidification could cause dry nasal passage and dry cough. She said it place residents at risk for nose bleeds and pain. During an interview on 09/18/24 at 3:54 p.m., the DON said a trach care in-service was given last year and when Resident #190 was admitted . She said all nursing staff were in-serviced with return demonstration. She said it was recommended to have 2 people when changing the trach holder but not required. She said she did not know if the facility's policy stated 2 people had to be present when changing the trach holder. She said she taught the nursing staff to clean around the trach site with sterile water or normal saline. She said sterile water should have been used for Resident #190's trach care if there was a physician order for it. She said items in trach kit should not be touched with non-sterile gloves. She said the trach kit became dirty when that happened. She said using items from a dirty trach kit placed resident at risk for infection. She said the infection was the negative outcome for staffing not performing trach care using aseptic technique (a method used to prevent contamination with microorganisms). She said nursing staff were only supposed to use the cotton-tipped applicators to clean inside the trach. She said using anything else to clean inside the trach could cause difficult breathing. She said LVNs were responsible for making sure water was in the humidification bottles. She said the CNAs should also monitor the water level and notify the LVNs. She said no humidification could cause dry mucous and nasal congestion. During an interview on 09/18/24 at 4:30 p.m., the ADM said that all staff should be ensuring residents had water in the humidification bottle. Record review of LVN Q's Trach Care and Suctioning/ Competency Checklist dated 09/23/23 indicated .demonstrates competency .able to perform trach care safely and effectively with sterile technique .understands what the various trach supplies are used for and how to properly use them .understands the procedure for replacing a trach tube . Record review of LVN Q's Trach Care and Suctioning Inservice dated 09/04/24 indicated .wash hands .assemble equipment and supplies .explain to patient what you are going to do .wearing gloves, remove and dispose of the soiled dressing .if pt has a disposable inner cannula, remove by squeezing clips on sides of inner cannula and dispose .wearing clean gloves, replace with new disposable cannula by clipping onto outer cannula .if pt has a non-disposable, remove by grasping outer cannula firmly and twisting inner cannula until it unlocks, place in a sterile basin of hydrogen peroxide to soak for 2 mins .use pipe cleaners and/or brush from trach care kit to clean inside tube .when clean, rinse in sterile basin of normal saline .wearing clean gloves, rinse again in another basin of normal saline to be sure peroxide is rinsed off .shake excess normal saline off tube but do not dry, small amount of normal saline is needed for reinsertion .replace clean non-disposable inner cannula, by holding outer cannula firmly and twisting inner cannula to locking position .using sterile cotton-tip applicators, dip in peroxide and use to clean under trach neck plate and around stoma opening .dispose of each applicator after use .continue this until foaming stops and area is clean .use sterile cotton-tip applicators, dip in normal saline bottle or sterile container and use normal saline to rinse off peroxide from under neck plate and around stoma area .dispose of each applicator after use .gauze with normal saline can also be used to clean and rinse the area .dry area with gauze, if needed .replace drain sponge underneath trach neck plate .if pt's trach holder is soiled, replace with a new one .have a 2nd person hold the trach tube securely in place while the holder is replaced .Do Not attempt to change the trach tube holder by yourself .passed trach care competency . Record review of facility policy titled Oxygen Administration revised in October of 2010 revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration The date and time that the procedure was performed. Record review of the facility's Tracheostomy Care revised on 08/2013 indicated .the purpose of this procedure is to guide tracheostomy care and the cleaning of reusable cannulas .equipment and supplies: gloves (clean and sterile) .tracheostomy care kit .hydrogen peroxide .sterile water or normal saline .pulse oximeter .aseptic technique must be used: during cleaning and sterilization of reusable tracheostomy tubes .during all dressing changes until the tracheostomy wound has granulated (healed) .during tracheostomy tube changes, either reusable or disposable .sterile gloves must be used during aseptic procedures . 45643

Based on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 24 residents (Resident #7, Resident #17, and Resident #50) reviewed for reasonable accommodations. The facility failed to ensure Resident #7, Resident #17, and Resident #50's call button was within reach while in bed. These failures could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity. Findings include: 1. Record review of Resident #7's face sheet, dated 4/19/24 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Pneumonia (a lung infection that causes the air sacs in the lungs to fill with fluid or pus, which can make breathing difficult and painful), Dementia (a group of conditions that cause a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), and Hypertension (a chronic medical condition that occurs when the pressure in your blood vessels is consistently too high.) Record review of Resident #7's quarterly MDS assessment, dated 07/25/24, revealed Resident #7 had a BIMS of 99, which indicated she was unable to complete the BIMS test. Shows that resident #7 requires extensive assistance with ADLs. Record review of Resident #7's Comprehensive Care Plan revised 012/20/22 reflected Resident #7 was Resident had an ADL self-Care Performance Deficit regarding her disease process, immobility, and poor cognition. During an interview and observation on 9/16/24 at 9:55 a.m., it was observed that Resident #7's call button was laying on the floor. It was observed that Resident #7's bed was in the high position. Resident #7 said that her call button had been laying on the floor all night and all morning. She said that she could not reach the call light button. She said if she needed help, she would not be able to ask for help and she would have to wait until someone came into her room. 2. Record review of Resident #17's face sheet, dated 1/4/24 revealed a [AGE] year old female admitted on [DATE] with diagnoses that included Systolic Heart Failure (occurs when the left ventricle of the heart is too weak to pump enough blood to the body), Hypertensive Herat Disease (a constellation of changes in the left ventricle, left atrium, and coronary arteries as a result of chronic blood pressure elevation), Old Myocardial Infarction (a previous heart attack that's detected by an electrocardiogram (ECG) as pathologic Q waves in the heart). Record review of Resident #17's annual MDS assessment, dated 07/24/24. The MDS indicated a BIMS score of 12 indicating Resident #17's cognition was moderately impaired. The MDS indicated Resident #17 required partial assistance from staff for activities of daily living. Record review of Resident #17's Comprehensive Care Plan revised 07/29/24 reflected Resident #17 required staff to, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an interview and observation on 9/16/24 at 9:38 a.m., Resident #17's call button was observed far under her bed. She said she never pushes her call button because she can never reach it. She said that she would use it to call for help, but she would need someone to give it to her. She asked the surveyor to pick the call button off the floor for her. 3. Record review of Resident #50's face sheet, dated 2/22/23 revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included Muscular Degeneration (a group of genetic diseases that cause progressive muscle weakness and breakdown), Hyperlipidemia (a condition where there are high levels of lipids, or fats, in the blood), Hypertension (a chronic medical condition that occurs when the pressure in your blood vessels is consistently too high.) Record review of Resident #50's quarterly MDS assessment, dated 08/14/24, revealed Resident #50 had a BIMS of 08, which indicated she had moderately impaired cognition. Shows that resident #50 requires extensive assistance with ADLs. Record review of Resident #50's Comprehensive Care Plan revised 03/10/23 reflected Resident #50 required staff to, Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. During an observation on 9/16/24 at 9:50 a.m., Resident #50's call button was laying on the floor behind a dresser. Call button was several feet away from the resident and behind furniture. Surveyor had to move the dresser away from the wall in order to get to the call button. During an interview on 9/18/24 at 1:32 p.m., with CNA L she said it was the responsibility of CNAs to ensure residents have call buttons within their reach. She said if a resident could not reach their call light or have the ability to get up and get their call light then they would have no way to communicate to staff if they needed help or assistance. She said this could place residents at risk of not getting the help they needed. During an interview on 9/18/24 at 3:15 p.m., with the DON she said that all staff are responsible for ensuring that residents call buttons were within reach. She said that if a resident that was dependent for care could not reach their call button they would not be able to ask for help. During an interview on 9/18/24 at 3:30 p.m., with the ADM he said that all staff are responsible to ensure that residents have a call button within reach when they are entering and leaving residents rooms. He said residents who needed help were placed at risk if they were unable to reach their call button. Record review of the facility's policy Answering the Call light revised September 2022 reflected . The purpose of this procedure is to ensure timely responses to the resident's requests and needs Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor.

Based on interview and record review the facility failed to ensure that that all alleged violations involving a drug diversion were reported after the allegation was made to other officials (including to the State Survey Agency) in accordance with State law through established procedures for 1 resident (Resident #25) of 4 resident reviewed for drug diversion in that: The facility was made aware of a possible drug diversion on 07/12/2024. LVN M reported to the ADM receiving a bottle of hydromorphone from Hospice Nurse N that was tampered with upon receipt of the medication. This failure could result in allegations or instances of resident drug diversion not being reported or investigated by the state survey agency. Findings include: Record review of an undated face sheet indicated Resident #25 was a [AGE] year-old male admitted to the facility on [DATE] with the diagnoses of Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), COPD (A group of lung diseases that block airflow and make it difficult to breathe), and diabetes mellitus. Record review of a quarterly MDS dated [DATE] indicated Resident # 25 had a BIMS of 06, which indicated cognitive impairment. He required extensive to dependent assistance with ADLs such as transfer, bathing, and toileting. Resident #25 had no pain, and no pain medication was administered. During an interview on 09/17/2024 at 10:00 a.m., Resident #25 was able to answer limited questions. He stated his name and date of birth. He stated he had no pain and was doing fine. During an interview on 09/17/2024 at 10:30 a.m., Resident #25's family stated he was informed of the mishandling of his father's pain medication on 08/23/2024 by a nurse that worked for the state. He stated he was not notified prior to that day of the mishandling of his father's pain medication. He stated he was not greatly concerned about the information because his father rarely complained of pain. During an interview with HHS Nurse O on 09/18/2024 at 10:20 a.m., she stated she worked a reported complaint on 08/23/2024 regarding Hospice Nurse N. She stated the complaint alleged Hospice Nurse N ordered a bottle of hydromorphone for Resident #25 on 07/06/2024 and delivered it to the facility on [DATE]. Upon receipt of the hydromorphone, LVN M noticed the medication was tampered with and reported the information to the ADM. The ADM notified the hospice company on 07/08/2024 of the incident. The hospice company sent RN P out to retrieve the medication to have it tested . HHS Nurse O stated she advised the ADM that he should have reported the incident as a drug diversion because it was the facility's resident whose medication was diverted. She stated he said he had not looked at the situation in that manner, but he would report the incident immediately. HHS Nurse O stated it had not harmed the resident because he had 3 unused sealed bottles of hydromorphone on the medication cart if he needed them for pain control. During an interview on 09/18/2024 at 11:45 a.m., Hospice Nurse P stated the medication was picked up from the facility on 07/10/2024 by herself. She stated instantly she knew the medication had been tampered with. She stated the seal was broken and the liquid was clear and thin like water. She stated hydromorphone was generally thicker in nature. She stated it was not best practice to keep narcotics overnight at their homes. She stated the nurse should have delivered the medication the same day she received it. She stated the nurse should have never reordered the medication if Resident #25 was not low on the medication. She stated all the details lead to a referral of Hospice Nurse N's license. During an interview on 09/18/2024 at 12:20 p.m., the ADM stated he was made aware of the medication tampering on 07/07/2024 by LVN M. He stated the next day when he came into work, he called the hospice company and informed them of the situation. He stated a few days later Hospice RN P came and retrieved the medication. He stated he never thought of the situation of a drug diversion that he would have needed to report because it was not his nurse that diverted the drug. He stated he thought the hospice company would call in the diversion on their end. He stated he had not investigated the situation any further because it was cut and dry to him. He stated he reported the incident to HHS and called the local police after HHS Nurse O suggested to him he needed to. He stated had he thought once the Hospice company had investigated it the situation was resolved. Record review of an undated policy entitled Reporting revealed, nursing facilities must report all allegations of drug theft (diversion) within 24 hours to the State survey and certification agency (State survey agency), and to other officials in accordance with State law.

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 5 residents reviewed for pain. (Resident #1) Resident #1 complained of pain in her heel prior to wound care. She complained of pain during the wound care treatment and at no time was the wound care held or pain medications offered. Review of Resident #1's physician orders indicated she did not have any PRN pain medications ordered. This failure caused the resident to experience pain during wound care. Findings included: Record review of Resident #1's face sheet dated 4/23/24 indicated she was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses was diabetes, muscle wasting and difficulty walking. Record review of Resident #1's Admission MDS dated [DATE] indicated she was cognitively intact. The MDS indicated Resident #1 did not have pressure injuries when admitted to the facility. The resident required partial to moderate assistance with sitting on the side of the bed, and from sitting to standing, and transfers. Record review of Resident #1's Baseline Care Plan (with no date) indicated she was alert and cognitively intact with some confusion at times. Resident #1 required the assistance of one person for bed mobility. She was totally dependent of staff for transfers and toileting. She used a manual wheelchair for ambulation. The care plan indicated she was at risk for pressure injuries. There was no indication of pain noted. Record review of Resident #1's Pain assessment dated [DATE] indicated the resident stated she had mild pain in the last 5 days but was unable to indicate the frequency, if it affected her sleep or any activities that contributed to the pain. Record review of Resident #1's skin assessment dated [DATE] indicated she had an area on her left heel that measured 2cm x 2 cm and was not painful. Record review of Resident #1's computerized physician order dated 4/23/24 indicated an order dated 4/19/24 to cleanse unstageable of the right posterior heel with wound cleaners, and pat dry and then apply Medi Honey, and then border gauze. There was no order for pain medication noted. During an observation and interview on 4/23/24 at 10:05 a.m., of Resident #1 was in her room in bed. The treatment nurse said she had a wound on her right heal that she was going to treat. The Treatment nurse took off Resident #1's socks. The sock from the right foot had drainage from the wound or medication that had soiled the sock. Prior to the nurse starting the treatment Resident #1 said her heel hurt, the treatment nurse did not ask her if she wanted anything for pain. She removed the socks and the bandage on her heel and throughout the procedure. The resident said ouch, ouch, ouch several times with a facial grimace. The nurse took the bandage off. The Treatment Nurse used Q-tips to put medication on the wound and bandaged it and during the whole procedure the resident was saying ouch, ouch, ouch The nurse said that she covered the wound with Med-honey and gauze. Resident #1 was still saying ouch that hurts when the Treatment Nurse finished the procedure. Resident #1 said that her foot was still hurting and it had been hurting since they started doing treatments. Resident #1 said she would have liked something for pain prior to getting wound treatment. Resident #1 said she had something last night, but it was too long ago to make a difference this morning. During an interview on 4/23/24 at 10:17 a.m., the Treatment Nurse said she did hear Resident #1 say she was in pain and her continued indications that she was in pain. She said Resident #1 had complained of pain the day before when she had completed wound care. She said she did not think to ask her if she wanted anything for pain. She reviewed her orders to see if she had recently gotten something for pain and said she did not have anything ordered. She said she would check with nursing staff to see if they could get her something ordered. During an observation and interview on 4/23/24 at 3:30 p.m., Resident #1 was seen propelling her wheelchair around with her feet. She had on socks and one resident asked why she was grimacing when she moved. She told her that her heel was tender and hurt sometimes. She said earlier today when she was receiving wound care her pain was likely a 4 on a scale of 1-10. ( with 10 being the worsest) During an interview on 4/23/24 at 4:40 p.m. the DON said the first time she heard Resident #1 was having pain was today. They had contacted the physician and gotten an order for PRN Tylenol for pain. Review of the facility Pain Assessment and Management Policy revised October 2022 indicated pain management is defined as the process of alleviating the resident's pain based on his or her clinical assessing and potential for pain, recognizing the presence of pain, identifying the characteristics of pain, and addressing the underlying causes of pain. Assess a resident whenever there is a suspicion of new pain or worsening of existing pain. Review the resident's clinical record for conditions or situations that may predispose the resident to pain, including wound conditions such as pressure, venous or arterial ulcers. Strategies consist of establishing a treatment regimen that is specific to the resident based on current medication regimen, nature and severity and causes of pain.

Based on observation, interview and record review the facility has failed to ensure the resident environment remained as free of accident hazards as possible and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Residents #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1's wheelchair brakes were functioning correctly to prevent a fall in her bathroom which resulted in a fracture. This failure could place residents at risk of injury from accidents and hazards. Findings include: Record review of Resident #1's face sheet, dated 09/19/23, indicated a [AGE] year-old female who was admitted to the facility on [DATE], with a readmission on 12/01/22. Resident #1 had diagnoses which included generalized muscle weakness, history of falling, age-related cognitive decline (experience of worsening or more frequent confusion or memory loss), age related osteoporosis (is a bone disease that develops when bone mineral density and bone mass decreases, or when the quality or structure of bone changes) without current pathological fracture (a complete or partial break in a bone), muscle wasting and atrophy (shortening), and difficulty in walking. Record review of Resident #1's quarterly MDS assessment, dated 08/02/23, indicated Resident #1 was usually understood and usually understood others. Resident #1 had clear speech, minimal difficulty hearing, and adequate vision with corrective lenses. Resident #1 had a BIMS of 11, which indicated moderate cognitive impairment. Resident #1 required limited assistance for transfer and toilet use. Resident #1 had was not steady, but able to stabilize without staff assistance for moving from seated to standing position, moving on and off toilet, surface-to-surface transfer (transfer between bed and chair or wheelchair). Resident #1 used a wheelchair. Resident #1 had occasional urinary and bowel incontinence. Resident #1 had not experienced falls since admission/entry or reentry or prior assessment. Record review of Resident #1's care plan, dated 02/11/23, with revision on 06/22/23, indicated Resident #1 had an actual fall with a bruise to buttocks due to unsteady gait. Interventions included continue interventions on the at-risk plan. Place call don't fall sign in room for resident reminder to call. Record review of facility incident report dated 09/19/23 at 10:25 a.m., completed by LVN A, indicated Resident #1 had pulled emergency light in bathroom .Resident #1 was noted to be on the bathroom floor, sitting facing the toilet with her body under the sink .Resident #1 was attempting to transfer from wheelchair to toilet .redness to left elbow, left lower back, left 2nd and 3rd knuckles, left shoulder, and red marks to front of neck .orders were received to set up an orthopedic (is the medical specialty that focuses on injuries and diseases of your body's musculoskeletal system (includes bones, muscles, tendons, ligaments and soft tissues)) consult .MRI (scan uses a strong magnetic field and radio waves to create detailed images of the organs and tissues within the body) to determine if this is new fracture, and pain medications was adjusted .physical therapy made aware and would like MRI results to decide treatment . Record review of Resident #1's x-ray report, dated 09/19/23, indicated compression fracture of the L2 (is the second lumbar spinal vertebra in the human body) vertebral body (is a type of break in the bones in your back that stack up to form your spine) is of indetermined age. During an interview and observation on 09/19/23 at 11:30 a.m. revealed Resident #1 was sitting in her recliner with her legs elevated by the footrest. Resident #1 had a grimace of face and slight bouncing of her legs. Resident #1 had a moderate area of redness noted to the chest underneath her chin. Resident #1 said she was in pain. Encouraged Resident #1 to call for assistance. Resident #1 pushed the call light and LVN A arrived. LVN A said she had just given her some pain medication and then told Resident #1 to give it some time to work. Resident #1 said my arms, shoulders, back, and pelvis hurts. I fell in the bathroom. LVN A said Resident #1 fell in the bathroom not too long ago and said the doctor ordered an x-ray. Resident #1 said my left wheelchair brake is loose and when I was trying to get my feet set to transfer, it moved. Resident #1 said she had told someone recently about her brakes being loose and no one had done anything about it. Resident #1 said she did not remember who, but she thought it was a male. LVN A and the State Surveyor set both brakes on the wheelchair and the wheelchair was able to be pushed back. During an interview and observation on 09/19/23 at 2:15 p.m., the Maintenance Supervisor said he was responsible for the maintenance of resident's wheelchairs. He said he did not have a process or schedule of checking resident's wheelchairs. The MS said he only knew if a wheelchair had issues if therapy or the resident told him. He said he had tightened Resident #1's wheelchair brake about 3 months ago. The MS said he had not recently received a maintenance order about Resident #1's wheelchair but he had worked on it because Resident #1 was particular about things. He said after the incident today (09/19/23) with Resident #1, he went to tighten the left brake but did not feel like it was loose beforehand. The MS went to Resident #1 room and moved the hardware on Resident #1's wheelchair that held the left brake lever to its former position, locked both brakes, and the wheelchair moved. He said, I guess the brake was a little loose. He said he had been the only maintenance work for a while, and it was hard to keep up with everything. The MS said it was important to provide maintenance to resident's wheelchair to prevent accidents. During an interview on 09/19/23 at 2:20 p.m., CNA B said she was Resident #1's aide today from 6am-2pm. She said she was in another room when Resident #1 fell in the bathroom. CNA B said LVN A came and got her to help her get Resident #1 off the floor. She said Resident #1 told her she fell because her wheelchair moved when she tried to stand up. CNA B said she had not touched Resident #1's wheelchair this morning so she did not know the brakes were loose. CNA B said after the incident before the MS tightened the brake, she pushed both brakes on Resident #1's wheelchair and it still moved. During an interview on 09/19/23 at 3:05 p.m., LVN A said she went to Resident #1's room because her emergency call light came on. She said when she arrived Resident #1's wheelchair was in the doorway, and she was on her left side on the floor between the sink and toilet. LVN A said Resident #1 scratched her chest on the raised seat handle. She said Resident #1 told her she slid trying to get her feet underneath her, but the wheelchair moved. LVN A said she had not noticed Resident #1's left brake being loose, and Resident #1 had not reported it to her. She said Resident #1's wheelchair did move even though the brakes were locked early when her and I [State Surveyor] tested it. LVN A said maintenance took care of resident's wheelchairs. She said the facility used a special computer system to report maintenance issues, but it was currently not working. LVN A said they also directly told the MS about maintenance issues too. LVN A said it was important to report maintenance issues and for wheelchair brakes to work properly to prevent falls and accidents. During an interview on 09/20/23 at 1:20 p.m., the DON said the MS was responsible for the upkeep and maintenance of resident's wheelchairs. She said the facility had just hired a maintenance assistant. The DON said when as issue was reported the MS, he immediately fixed it. The DON said staff reported maintenance issues by a computer program or verbally. She said she did not know his schedule for equipment maintenance. The DON said Resident #1 was able to safely transfer herself. She said when wheelchair brakes did not function correctly, it could lead to incidents. During an interview on 09/20/23 at 2:25 p.m., the ADM said the MS was responsible for resident's wheelchairs. He said it would be impossible to have a maintenance schedule for resident's wheelchairs. The ADM said therapy, staff or the resident had to inform them if their wheelchair had issues. He said he just had an in-service today over reporting maintenance issues timely. The ADM said a loose brake on a wheelchair could cause the resident to have an accident. Record review of a Fall and Fall Risk, Managing policy, dated 03/18, indicated .environmental factors that contribute to the risk of falls included .improperly fitted or maintained wheelchairs Record review of a facility Maintenance Service policy, dated 12/09, indicated .maintenance service shall be provided to .an equipment .the maintenance department is responsible for .and equipment in a safe and operable manner .the maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable condition Record review of a Safety and Supervision of Residents policy, dated 07/17, indicated .our facility strives to make the environment as free from accident hazard as possible .resident safety and supervision and assistance to prevent accidents are facility-wide priorities

Based on observation, interview and record review, the facility failed to ensure nursing staff demonstrated competencies and skill sets necessary to care for resident needs for 1 of 8 residents reviewed for competent nursing staff. (Resident #1) LVN A did not report Resident #1's skin tear to the resident's family, hospice company, physician, or other facility staff members. The resident's skin tear was found two days later by facility staff. Her arm was warm, red, and swollen, required wound care and an antibiotic. These failures could place all residents at risk for inadequate treatment and interventions based on inaccurate assessments of their medical needs and conditions. Findings included: Review of Resident #1's face sheet, with a print date of 6/2/22, indicated she was admitted on [DATE], was [AGE] years old, and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's June Order Summary Report indicated an order (with an order date of 5/20/22 and a start date of 5/31/22) for cleaning a skin tear to the resident's left elbow with normal saline, pat dry, apply petroleum jelly, gauze, and cover with island dressing every day. Staff were to monitor for bleeding and/or bruising every shift and if any occurred, notify the physician. an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's undated care plan, indicated she had an actual impairment to skin integrity related to fragile skin and had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . to physician. As well as using caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care area and interventions all had initiation dates of 5/31/22. Review of Resident #1's MDS dated [DATE] indicated she had moderate difficulty hearing, unclear speech, usually understood others, was usually understood, and had moderately impaired vision. She had short and long-term memory problems and severely impaired decision-making skills. She had continuous inattention and altered level of consciousness. She had physical and verbal behaviors directed at others, other behaviors not directed at others and rejected care. She was totally dependent on one staff member for bed mobility, dressing, eating, toileting, hygiene and 2 staff members for transfers. She used a wheelchair for mobility. The MDS did not address any skin issues. Review of Resident #1's Weekly Skin Assessment completed by LVN A, dated 5/28/22, indicated the resident had a skin tear to her left elbow measuring 3cm x 1cm, with steri-strips applied. Review of a nurse's note completed by LVN A with a late entry date of 5/31/22 for the date of 5/28/22 at 2:00 p.m. indicated Resident #1 was sitting in her wheelchair in the common area. She started to slide down in her chair and was repositioned to a proper sitting position x 3 staff. She bumped her left elbow on the wheelchair arm which caused a skin tear. The area was cleansed with normal saline and steri-strips were applied. Review of a nurse's note completed by LVN B on 5/30/22 at 5:48 p.m., indicated a CNA reported the resident had a noted change in condition. LVN B began assessing Resident #1 and noted a dressing to her upper left arm at the elbow. The resident's skin was described as red and warm from the skin tear down to the top of her left hand. The resident's hospice company and family were notified. Review of a nurse's note completed by LVN B on 5/30/22 at 6:30 p.m. indicated Resident #1's hospice company arrived and assessed the resident. The hospice nurse provided an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Wound care was provided at that time and the resident tolerated it well. Review of a nurse's note completed by LVN C on 5/31/22 at 11:07 a.m., indicated the rResident #1 had a dressing on her left arm. The resident's left arm was red and warm to touch. The resident's family member expressed he was worried about infection. The resident's hospice provider was called and a new order for [MEDICATION(S)] 1gm IM daily x5 days for infection was received, as well as a new order for left arm x-ray. The [MEDICATION(S)] injection was administered to the resident's right deltoid and wound care to her left arm was completed. Review of a nurse's note completed by LVN C on 5/31/22 at 1:07 p.m., indicated no fractures or breaks were found from the left arm x-ray. The nurse notified the resident's hospice provider and family. During an interview on 6/1/22 at 11:05 a.m., LVN C said she said she did not work on 5/28/22 or 5/29/22. She said on Friday, 5/27/22, Resident #1 did not have a wound to her left arm. She said on Monday (5/30/22) morning, she had gone in to check on the resident and noted a little vomit to her right shoulder area, so she called the aide to help get the resident cleaned up and changed. She said she did not assess the resident's skin because it was not the resident's skin assessment day. She said she was at home on Monday (5/30/22) night and received a phone call from the DON asking if she knew about the resident's arm having a wound and bandage. She said she was not aware of the resident having a wound or a bandage and was never told about it by other staff members. She also said it was not on the 24-hour report. She said in the event something like this happens, the 24-hour report should be updated to reflect the change and staff should pass it on during shift change. She said yesterday on 5/31/22, CNA D mentioned seeing the dressing on the morning of 5/30/22 while she got the resident changed after vomiting. The nurse did not know what the date of the dressing was on Monday, as she had not seen it herself and when she returned to work on Tuesday morning it had already been changed on Monday night. She said orders were already in the computer on Tuesday morning for wound care and to change the dressing daily. During an observation on 6/1/22 at 11:15 a.m., Resident #1's wound edges were well approximated and the flap of skin that had been pulled back was laid flat and steri-stripped down. The wound appeared clean and had no drainage or odor. The resident's arm was red from her elbow to her wrist and appeared slightly swollen. LVN C said the resident's swelling had gone down considerably. She said she did not know when or how the large skin tear occurred. She said since hospice was involved in the resident's care, they had to get orders for x-rays and antibiotics through them or must request those things to be approved. She said the resident's arm was x-rayed yesterday and nothing was found except for soft tissue swelling and arthritis. She said the resident was on a 5-day [MEDICATION(S)] IM injection to prevent infection and she was giving it to the resident in her right arm. During an interview on 6/1/22 at 11:45 a.m., CNA D said Resident #1's left arm had a patch on it, like a bandage. She said it was already there when she came to work on Monday (5/30/22) morning. She said she didn't read it, so she didn't know what date was on it. She said she did not tell LVN C about it because it was already there, so she thought the nurse already knew. She said yesterday LVN C asked her if she'd noticed anything wrong with the resident's arm. She said the nurse did not know anything about the wound. She said she let her relief know when she got ready to leave at shift change. She said she was not told anything about it in report on the morning of 5/30/22 from the 5/29/22 night shift CNA. The weekend aide told her that on Sunday morning she did not see a patch on the resident's elbow. During an interview on 6/1/22 at 12:00 p.m., LVN E said she worked over the weekend, on 5/28/22 and 5/29/22. She said Resident #1 did not have anything wrong with her arm and pretty much slept all day on Sunday (5/29/22). She said she thought the resident's nurse was LVN A. She said she first heard about the resident's arm wound that morning (6/1/22) when she came into work. During an interview on 6/1/22 at 12:17 p.m., LVN A indicated she was the nurse who was working when Resident #1's left arm sustained the skin tear. She said she noticed the resident was in her wheelchair and started slipping down in the chair. She said it was herself, LVN F and CNA G who repositioned the resident. She said they lifted the resident up with the Hoyer-pad underneath her. She said the resident's left arm bumped the chair when they repositioned her. She said when she looked at the resident, she noted the resident had a skin tear to her elbow. She said she got the supplies to clean the wound and bandaged it. She said when she last saw the resident's arm it only had a skin tear and there was nothing else wrong with it. She said she forgot to document it because she had a crazy day. She said she did not notify hospice, but she believed she told her relief verbally about the skin tear. She did not remember if she put it on the 24-hour report. She said she wasn't sure if she told any of her aides about the resident's arm having the skin tear. She said she did not notify the resident's family either and she realized she dropped the ball. She said they did have standing treatment orders for skin tears and wounds and those orders were what she used to care for the resident's wound. She said she knew she should notify the resident's family, doctor, hospice provider, and so on. During an interview on 6/2/22 at 12:00 p.m., LVN F said she helped LVN A lift Resident #1 up in her wheelchair. She said LVN A mentioned the resident did not look comfortable in her chair. LVN F, LVN A and another person (she didn't remember who) helped lift the resident up in her chair. She said the resident did not ever make a sound or act as if she was hurt. She said she was not aware the resident had a wound to her left arm. She said the resident's family member showed her the wound to the resident's arm on Tuesday (5/31/22) morning. A call was placed to CNA G on 6/1/22 at 12:41 p.m., Nno return call was received. During an interview on 6/1/22 at 12:42 p.m., LVN H said she received report from LVN B on Monday (5/30/22) night that Resident #1 had a skin tear on her left arm. She said the skin tear was added to the 24-hour report on Monday evening. She said usually changes like those would require an incident report, calling the family, the doctor, give the notification during shift change and put it on the 24-hour report. During an interview on 6/1/22 at 1:07 p.m., LVN B said Resident #1 had a change in condition per the CNA and that she wasn't eating or responding. She went in the room to assess the resident and when they pulled back the covers, she saw the bandage to the resident's left arm. She did not remember if it was dated. She said she was not told at the 2 p.m. shift change on 5/30/22 that the resident had a skin tear to her left arm. She said it was steri-stripped and the rest of the resident's arm was red and warm, almost hot. She said she gave the hospice nurse report about the skin tear and the redness/warmth to her arm. She also let the resident's son know about it and the DON. She said she went into the resident's chart to see if there was anything previously documented about the skin tear and she saw a skin assessment from 5/28/22 regarding the skin tear. She said the wound care order she put into the computer was from hospice and by the time she arrived at the facility yesterday, the x-ray had already been ordered and obtained. She said she did not recall the skin tear being on the 24-hour report, so she initiated it on Monday evening. She said it's best to notify the family, hospice, the doctor, and anyone else immediately, as soon as you identify the issue. She said they should also always convey these issues in shift report and put it on the 24-hour report. During an interview on 6/1/22 at 1:28 p.m., Resident #1's family member said he was at the facility on Monday (5/30/22) morning. He said he left the facility and as he walked into his home, he received a call that she had a change in condition, and he returned to the facility. He said the hospice nurse went to look at the resident's body to assess her and that's when they all saw the resident's left arm. The facility staff told the resident's family they did not know what had occurred with her arm, but they would find out. During an interview on 6/1/22 at 3:50 p.m., the DON said she spoke with LVN B on Monday (5/30/22) evening at around 6 p.m. about the Resident #1's change in condition. The DON said LVN B told her the resident had a dressing to her left elbow but there was no incident report and nothing on the 24-hour report. The DON said she called LVN A to ask her what happened, and LVN A told it happened while she and 2 other staff members lifted the resident back into her chair. She said she did an in-service on Tuesday with staff and coaching with LVN A about incident reports and notifications. She said LVN A followed the standing order the facility has per the medical director about how to treat skin tears, but she did not transcribe it into the resident's chart. She said she expects incident reports to be completed, doctors, families, and hospice providers to be notified, 24-hour reports to be updated and any standing orders used to be transcribed into the computer. During an interview on 6/2/22 at 10:55 a.m., hospice RN J said she was called on Monday (5/30/22) morning for Resident #1 vomiting. She said the resident was laying more to her left side, so she did not see her arm. She said she took the resident's blood pressure on her right arm. She said later that evening at around 5:30 p.m. she said she got another phone call to come back to the facility because the resident had stopped responding. She said she was called because the family was concerned the resident looked like she was about to pass away. She said LVN B told her about the resident's skin tear to her left arm and that she was unsure how it had occurred, but she was investigating it. LVN B told the hospice nurse that she saw charting about it on 5/28/22 but was unsure of any of the details. The hospice nurse said the resident's family told her they had not heard about this wound before now and that her arm did not normally appear the way it currently did. She said the wound was dressed with an undated dressing. She said the resident's arm was red, swollen, and hot to the touch. She said she got an order from the facility medical director for a [MEDICATION(S)] IM injection for the possible infection. She said the resident could not swallow medication, so she got the injectable medication which she said the resident should still be on. She said when she informed the facility medical director, it was also her first-time hearing about this wound as well. During an interview on 6/2/22 at 11:41 a.m., hospice RN K said when she visited Resident #1 on 5/24/22 the resident's left arm did not have any redness, swelling or warmth to it. She said the resident's right arm did have a little skin tear to it, but hospice was already aware of this and it was healing well. She said she again saw the resident on 5/31/22 and the resident's left arm was red, swollen, and warm. She said on Wednesday 6/1/22 the resident's arm did appear to be improving and was less red, less swollen and was no longer warm. During an interview on 6/2/22 at 1:30 p.m., the DON said all nurses were taught upon hire at orientation that they were expected to notify the doctor and family if the resident had a change in condition and to transcribe orders or get orders if necessary . Review of a coaching form for LVN A indicated the DON spoke with her on 5/31/22 and instructed her to ensure she notify families with any resident changes such as bruising, skin issues. Incident reports were to be completed and orders for any and all wound care. She was also instructed to notify the physician with any changes. Review of facility in-service dated 5/31/22 at 8:30 a.m. and 1:30 p.m. indicated the nursing staff must notify family with any changes, complete incident reports at the time of the incident, put orders in place, add to 24-hour report sheet, and notify the physicians of changes. Review of the facility's Change in a Resident's Condition or Status policy, with a revision date of 2/2021, indicated: .1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): a. accident or incident involving the resident; b. discovery of injuries of an unknown source; . .d. significant change in the resident's physical/emotional condition; e. need to alter the resident's medical treatment significantly . .4.a nurse will notify the resident's representative when: a. the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; b. there is a significant change in the resident's physical, mental, or psychosocial status; . .8. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status .

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents, for 1 of 3 residents reviewed for accidents. (Resident #1) CNA A did not transfer Resident #1 with a Hoyer lift as indicated in his care plan. CNA A transferred Resident #1 alone and the resident fell off the bed and suffered a fracture to his right femur. (thigh bone) This failure contributed to Resident #1's right femur fracture. This failure could place residents who required the use of a Hoyer lift during transfers at risk for injury. Findings included: A face sheet dated 12/17/18 indicated Resident #1 was [AGE] years old, admitted [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] indicated Resident #1 was severely cognitively impaired and required assistance of 2 staff with bed transfers. A care plan updated 11/08/18 indicated Resident #1 required total assistance with two staff and the use of a Hoyer lift during transfers. A nursing progress note, for Resident #1, dated 12/14/18 at 11:30 p.m., indicated LVN B was informed by CNA A that Resident #1 was assisted to the floor by his bed. The note indicated Resident #1 was sent out to the local hospital for evaluation at the family request. An incident report dated 12/14/18 at 11:30 p.m., and revised on 12/17/18 at 6:37 a.m., indicated CNA A informed LVN B that she assisted Resident #1 to the floor by his bed. The report indicated when LVN B entered the room she saw Resident #1 sitting on the floor up against the bed. The incident report indicated Resident #1 appeared to have a dislocated knee. The incident report indicated the hospice nurse ordered an x-ray that was later cancelled, because the family requested that Resident #1 be sent to the local hospital. The report indicated that 911 was called to transport him to the local hospital. A hospital visit summary dated 12/15/18 indicated Resident #1 was being transferred from his wheelchair to his bed when he fell at the nursing home hitting his right leg. The summary indicated Resident #1's discharge [DIAGNOSES REDACTED]. During an interview on 12/20/18 at 10:06, a.m., the administrator said she was notified of Resident #1's fall until 12/17/18. During an interview on 12/20/18 at 2:30 p.m., CNA A said she had 3 days of training on the floor which included Hoyer transfers. CNA A said there should be 2 people during a Hoyer transfer. CNA A said on 12/14/18 she transferred Resident #1 by herself and did not use the Hoyer lift. CNA A said she had never used the Hoyer lift when transferring Resident #1 because she did not know the resident required a Hoyer lift be used during transfers. CNA A said she did not use a gait belt when she transferred Resident #1. CNA A said she transferred Resident #1 alone and had him stand and pivot from the chair to the bed and then sit down on the bed. CNA A said she did not know how Resident #1 slid off the bed, just knows it happened. CNA A said she immediately went and got her nurse when she realized Resident #1 was hurt. CNA A said she found out on Monday 12/17/18, from the DON that she should have used the Hoyer lift to transfer Resident #1. During an interview on 12/20/18 at 3:26 p.m., CNA A said she knew Resident #1 was hurt when she heard his knee pop and he said, oh! It's broke. CNA A said she felt Resident #1's hip sticking out. During a telephone interview on 12/20/18 at 4:17 p.m., LVN B said on 12/14/18 when CNA A reported that she had assisted Resident #1 to the floor she assessed Resident #1 and found the rotation of his knee was out of place and she knew he was hurt. She said his knee cap looked like it was by his thigh. LVN B said she called hospice and asked about an order for [REDACTED].#1's called, came to visit and requested Resident #1 be sent to the hospital. LVN B said 911 was called and Resident #1 was sent to the hospital. LVN B said she thought she called the DON regarding Resident #1 but did not because so much was going on. During an interview on 12/20/18 at 3:59 p.m., the administrator said Monday 12/17/18 was the first time she was notified of the incident with Resident #1. She said she reported the incident to the state agency at that time. The administrator said CNA A should have transferred Resident #1 with the Hoyer lift. The administrator said on 12/17/18 she conducted an in-service with all staff for residents who required assistance with transfers including transfers with Hoyer lift and use of gait belts. She said she also put in place a notification protocol, in writing, for residents who required Hoyer lift transfers. The administrator said she completed a fall protocol, a nurse aide competency, and nurse competency as well, to make sure staff knew what was expected. An in-service dated 12/17/18 conducted by the DON to nurses, medication aide, and CNAs indicated training was provided for transferring with Hoyer lifts, gait belts with 2 person assist as well as 1 person assist. The in-service also indicated that a green icon with the letter H would be posted to indicate the residents need for a Hoyer lift when transferring. The undated Hoyer policy and procedure indicated . working with two people for maximum safety, position the resident over the center of the bed in a back-lying position .

Based on observation, interview and record review, the facility failed to ensure care was provided based on a comprehensive assessment and treatment orders in accordance with professional standards of practice to prevent pressure injury development and promote healing for 1 of 6 residents reviewed for pressure injury. (Resident # 54) The facility did not provide offloading for pressure redistribution for Resident #54's pressure injury on his coccyx. Resident #54's previously healed pressure injury on his coccyx reopened and worsened from a stage 2 to a stage 3 pressure injury. This failure could place 9 residents who had pressure injuries at risk for the development and worsening of pressure injuries. Findings included: Physician orders [REDACTED].#54 admitted [DATE], was [AGE] years old, with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #54 was sometimes understood, and sometimes understood others and had severe cognitive impairment. He required extensive assistance of 2 staff for bed mobility, transfers, dressing, and toileting. Resident #54 was always incontinent of bowel and bladder and had one unhealed pressure injury stage 2 identified on 8/22/17. A physician telephone order dated 3/27/18 indicated Resident #54's treatment to coccyx was discontinued due to area healed. A Braden Scale dated 4/9/18 indicated Resident #54 was at mild risk for developing pressure injuries. A Physician telephone order dated 4/1/18 indicated Resident #54 had a new treatment order to cleanse the wound to his buttocks with wound cleanser, pat dry, apply [MEDICATION NAME] sheet and cover with dressing every day and as needed until healed. An order dated 5/4/18 indicated to cleanse coccyx with wound cleanser, pat dry, apply collagen powder and cover with dressing every day. A Skin Condition Fax Communication dated 5/8/18 indicated Resident #54 had a stage 3 pressure injury on his coccyx measuring 3.5 cm x 1.5 cm x 0.5 cm with no necrotic tissue. A Wound Care Specialist Evaluation dated 5/31/18 indicated Resident #54 had a stage 3 pressure injury on his coccyx of at least 22 days duration and no associated pain with the wound. The pressure injury measured 3 cm x 1 cm x 0.3 cm with 5% slough and 95% granulation tissue. The Plan of Care Recommendations included apply collagen once daily for 30 days and a dry protective dressing; reposition the resident per facility protocol and; off-load the wound. A care plan dated of 5/1/18 indicated Resident #54 developed a stage 2 pressure injury to the coccyx with moisture associated [MEDICAL CONDITION] around the open wound. Interventions included: Assess wound weekly, notify physician of changes, low air loss mattress, position the resident with pillows, and turn/reposition the resident every 1-2 hours. The updated care plan entries indicated the following: *5/1/18 - The pressure injury measured 3.5 cm x 0.5 cm x 0. *5/8/18 -the pressure injury deteriorated to a stage 3 and measured 3 cm x 1.5 cm x 0.5 cm. *5/10/18 - the wound care physician measured the stage 3 pressure injury as 3.5 cm x 1 cm x 0.3 cm. *6/1/18 - the stage 3 pressure injury measured 3 cm x 1 cm x 0.3 cm. During an observation on 06/04/18 at 12:32 p.m., Resident #54 was in bed with the head of bed elevated 45 degrees, eating lunch. After completing his meal, the staff lowered the head of bed and Resident #54 remained on his back. During an observation 06/04/18 at 2:02 p.m., Resident #54 was in bed on his back. During an observation and interview on 06/05/18 at 09:59 a.m., Resident #54 was on his back. LVN A said Resident #54 was bedbound and had a pressure injury to his coccyx. LVN A said Resident #54 had a pressure injury in the same area a few months ago that healed, but it reopened about a month and a half ago. She said Resident #54 was being followed by the wound care physician weekly and she did not know the stage of the pressure injury. LVN A said Resident #54 was on his back at 8:00 AM for breakfast. She said they usually use the pillows to off load the coccyx wound. She said the resident was not offloaded now. During an observation on 06/05/18 at 10:13 a.m., 11:16 a.m.,12:14 p.m., and 1:43 p.m., Resident #54 was positioned on his back. During an observation and interview on 06/6/18 at 9:43 a.m., Resident #54 was positioned on his back, CNA C placed her hand under Resident #54's buttocks and said the tailbone was on the mattress and was not offloaded. CNA C said she had been instructed to support Resident #54 with pillows, but no special instructions were given to her, to keep the resident's tailbone offloaded to prevent pressure over the pressure injury. During an observation and interview on 06/06/18 at 9:49 a.m., CNA C positioned Resident #54 onto his right side from his back. LVN B removed the self-adherent dressing from a macerated area of skin over the resident's coccyx and lower back. The adhesive was stuck to Resident #54's macerated skin. Two small areas of macerated skin were bleeding where the dressing had adhered. LVN B cleansed the wound and the large area of [MEDICAL CONDITION], red, and peeling skin around the pressure injury with wound cleanser and patted dry. The pressure injury measured 3.6 cm x 1.7 cm x 0.7cm; the wound bed was covered with 90% pale yellow slough, the wound edges were intact, with no drainage or odor. The macerated skin around the pressure injury measured 13.5 cm x 14.5 cm. Collagen powder was applied to the wound bed and a 4 x 4-inch dry absorbent dressing with self-adhering edges was applied. The adherent edges of the dressing were attached to the macerated skin. LVN B said this was the dressing they were using and did not obtain a larger dressing that would have covered the entire area. LVN B then applied Calazinc ointment (a protective barrier containing zinc and [MEDICATION NAME] lotion) to the macerated area surrounding the 4x4 dressing but did not apply to the peri wound under the dressing. During an interview on 06/06/18 at 10:26 a.m., the interim DON said she expected the staff to turn and off load every resident with pressure injuries at least every 2 hours. She said the pressure injury should be totally offloaded and residents with pressure injuries to the coccyx should limit the time on back. The interim DON said she expected the nursing staff to come to her with questions and would expect the dressing on Resident #54 not to adhere to the macerated skin around the pressure injury. She said a larger dressing would be indicated. A Preventative Skin Care Procedure with a review dated of 1/2018 indicated: Purpose: 1. To prevent the formation of decubitus ulcer .8. Inspect skin for redness, paying attention to reddened, irritated, or lacerated skin at any pressure point, especially bony prominences or any cold and blanched area .9. If redness does not readily disappear with gentle massage, the turning schedule should be shortened to every hour . According to the National Pressure Ulcer Advisory Panel, reviewed 6/8/18 from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The CMS 672 dated 6/4/18 indicated 9 residents had pressure injuries.