Every finding on record at Avir at Killeen

Based on observation, interview, and record review, the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 3 (Washer #1) washers and 2 of 3 (Dryer #2 and Dryer #3) dryers. The facility failed to maintain working washers (Washer #1) and dryers (Dryer #2 and Dryer #3) in the facility's only laundry room. This failure could put all residents at risk of infection, not having clean linen for their beds and diminished quality of life. Findings included: During an observation of the laundry room's dirty side on 08/22/2026 at 12:34p.m., revealed there were three industrial washers. Two of the washers were working and one had a sign on it that said BROKEN. There were also approximately 25 large trash bags full of laundry waiting to be washed. During an observation on the laundry room's clean side on 08/22/2026 at 12:38p.m., revealed that the facility had three industrial dryers. Two of the dryers were not in use. During an interview with the HKS on 08/22/2026 at 12:39p.m., she said the washer had been out for two weeks. She said they just fixed the other washer that had been out since she started about 3 years. She said one dryer had been out for a year and the other dryer had been out for six months. She said they have enough linen and towels, but they only have one dryer working and she cannot get all the clothes washed and dried that fast. She said one staff even took the clothes to the laundry mat to wash and dry the clothes on 08/21/2026. She said she cannot keep up with one dryer and two washers. During an interview with the ADM on 08/22/2026 at 5:48p.m., she said she had been trained on physical environment and working equipment. She said the policy for maintaining equipment was that the equipment was to be in good working order. She said maintenance and staff were responsible for ensuring the equipment was working properly. She said if the equipment was not working then the staff were to do a work order to get it repaired. She said Washer #1 had not been out very long. She said she was not sure how long Dryer #2 and Dryer #3 had been out. She said with the facility having one dryer and two washers could affect the residents because the residents could miss showers due to not having clean linen, not being able to have their bed sheets changed and could cause the residents to get infections. She said maintenance was monitored to ensure all equipment was in working order. She said the Maintenance director monitored through the work order system. She said the reason the facility had one dryer, and two washers was because the work on the broken ones just had not been completed. Record review of maintenance work order system dated 09/12/2025 revealed Dryer #2 was placed on hold. Comments on the work order was: [Staff Name #1] on [DATE], 2:16 PM: at [Staff Name #3] at [ADM], [Staff Name #3] - Please provide an update on this job, due to the cost of this project we will be needing a second quote, please obtain the quote and send it over to me at [Staff Name #1] [Staff Name #1] on [DATE], 5:02 PM: at [Staff Name #3], Please provide an update on this job. If you still need a second quote, please reach out to [Company Rep] with [Supply Company] [Staff Name #1] on [DATE], 11:44 AM: at [Staff Name #3], at [ADM], please contact [Supply Company] for additional quotes [Staff Name #2] [Staff Name #1] on [DATE], 11:40 AM: at [Staff Name #3] at [ADM], Can you please provide an update on the secondary repair quote? at [Staff Name #5] at [Staff Name #1] [Staff Name #3] on [DATE], 11:39 AM: at [Staff Name #1] at [ADM] at [Staff Name #4] We have added the quote from [Supply Company]. [Staff Name #2] on [DATE], 7:36 AM: [Staff Name #1] what is the status of this? at [Staff Name #1] [Staff Name #2] on [DATE], 5:49 PM: [Staff Name #1] what is the status of this? at [Staff Name #1][Staff Name #1] on [DATE], 6:03 PM: [Staff Name #2] Pending Review and Submittal.[Staff Name #2] on [DATE], 9:01 AM: [Staff Name #1], how many working dryers does the facility have vs. down dryers? at [ADM] at [Staff Name #1]. [Staff Name #1] on [DATE], 10:15 AM: at [Staff Name #3] Please reach out to [Supply Company] for an updated replacement quote. [Staff Name #3] on [DATE], 1:59 PM: I have gotten an updated quote from [Supply Company] about the dryer. at [Staff Name #1] at [ADM] at [Staff Name #6]. [Staff Name #2] on [DATE], 6:03 AM: at [Staff Name #7] at [Staff Name #8] at [Staff Name #2] Pending Final Approval. The dryer is approximately [AGE] years old and requires replacement of the drum and cylinder with repair costs quoted at $6,700. Replacement quotes range from $7,600 to $12,000. Due to the minimal cost difference and the units age, replacement is the most cost-effective option to ensure reliability and avoid further repairs. Census 94 of 120. Record review of work order for Washer #1 dated 08/13/2026 revealed a technician went out to the facility on [DATE]. The work for this job is not yet completed for the following reasons: Parts needed. Comments from your technician: Responded to a service call for a commercial washer displaying a file-related error code. Diagnosed the unit and determined that the hot and cold-water inlet valves are not operating properly and will need to be replaced. Unit is currently awaiting replacement hot and cold inlet valves to complete repairs. Building Services will follow up with the next actions. Record review of Maintenance Service Policy dated 12/2009 revealed Maintenance service shall be provided to all areas of the building, grounds, and equipment. Functions of maintenance personnel include but are not limited to maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. establishing priorities in providing repair service.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 5 medication carts (MC #1, MC #2, and 1 of 1 treatment cart (TC #3) reviewed for drug storage and labeling.The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors on 08/22/2026.The facility failed to ensure MC #2, was locked, medications secured, and not accessible to other staff, residents, or visitors on 08/22/2026.The facility failed to ensure TC #3, was locked, medications secured, and not accessible to other staff, residents, or visitors on 08/22/2026.This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications. Findings include:During an observation of the nurses' station on 08/22/2026 at 7:25a.m. MC #1 was against the nurses' station unattended and unlocked. The TC #3 was across from the nurses' station against the wall. LVN B was down 300-Hall out of sight of the cart. MC #1 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box. The TC #3 contained wound care solution, zinc oxide cream, barrier cream, and gel hand sanitizer.During an interview with LVN B on 08/22/2026 at 7:33a.m., she said MC #1 and TC# 3 were assigned to her. She said she was trained on medication storage. She said the policy was staff must lock the medication carts anytime they walked away from the carts. She said the nurse was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident could get into the medication cart and medications could disappear. She said the DON monitored to ensure the medication carts were locked. She said the DON monitored to ensure the medication carts were locked through observation. She said she had left the medication cart unlocked because she forgot she had the medication cart and the treatment carts were locked.During an observation of 200-Hall on 08/22/2026 at 7:35a.m., MC #2 was in the doorway of a resident's room. MA C was in the room with her back turned from the medication cart. MC #2 contained residents' prescription drugs, over the counter medications, and narcotics in a locked box.During an interview with MA C on 08/22/2026 at 7:36a.m., she said MC #2 was assigned to her. She said she was trained on medication storage. She said the policy was the medication carts were to be locked when staff walked away from it. She said the nurse or the MA on the cart was responsible for locking the medication cart. She said if staff left the medication cart unlocked and unattended a resident or staff member could take the medication. She said the DON monitored to ensure the medication carts were locked. She said the DON monitored to ensure the medication carts were locked through observation. She said she went to take the resident's vitals and forgot to lock the medication cart. During an interview with the DON on 08/22/2026 at 03:38p.m., she said she was trained on medication storage. She said the policy was that staff were to lock the medication cart whenever they were not near the cart. She said the nurse or medication aide who was on the medication cart was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended someone could steal the medication or a resident with dementia could take the pills. She said the DON and ADM monitored to ensure staff locked the medication cart. She said the DON and ADM monitored by doing observations. She said LVN B and MA C told her they had just stepped away; she said that was not acceptable.During an interview with the ADM on 08/22/2026 at 5:35p.m., revealed she was trained on medication storage. She said the policy for medication storage was that the medication cart was to be locked at all times unless the nurse or medication aide was getting something out of it. She said the nurse was responsible for ensuring the medication cart was locked. She said if the medication cart was left unlocked and unattended a resident or family member could get into the cart and take medications. She said the DON and ADON monitored to ensure the staff were locking the medication cart. She said the DON and ADON monitored by doing observations. She said she guessed LVN B and MA C forgot to lock the medication cart. She said she did not know why the treatment cart was left unlocked.Record review of Storage of Medications Policy, dated 02/2023, reflected The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others.

Based on interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure medications were administered in a timely manner to Resident #1. This failure could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.Findings include: Record review of Resident #1's face sheet, dated 08/22/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), tinea unguium (fungal nail infection), peripheral vascular disease (abnormal narrowing of arteries), hypertension (high blood pressure), hereditary and idiopathic neuropathy (nerve damage inherited from parent and unclear cause), Parkinson's disease (movement disorder of the nervous system that worsen over time) and anxiety (feeling of uneasiness or worry). Record review of Resident #1's admission MDS assessment, dated 05/06/2026, reflected Resident #1 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #1's physician orders, dated 07/18/2026, revealed Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease. Record review of Resident #1's Medication Administration Audit Report dated 08/22/2026 reflected Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease was to be given at 7:00a.m and Resident #1 did not it until 12:50p.m. on 08/08/2026. Record review of Resident #1's Medication Administration Audit Report dated 08/22/2026 reflected Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease was to be given at 7:00a.m. and Resident #1 did not get it until 3:43p.m. on 08/10/2026 according to LVN A's documentation. Record review of Resident #1's Medication Administration Audit Report dated 08/22/2026 reflected Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease was to be given at 3:00p.m. and Resident #1 did not get it until 5:41p.m. on 08/18/2026 according to LVN A's documentation. Record review of Resident #1's Care Plan, dated 07/22/2026, reflected Focus: The resident is on anitParkinson therapy Memantine r/t Parkinson's disease.Goal: The resident will be free of any discomfort or adverse side effects of anitParkinson therapy through the review date.Interventions: Administer ANTI-PARKINSON'S medications as ordered by physician.Monitor/document side effects and effectiveness Q-SHIFT. Interviews attempted with Resident #1 on 08/22/2026 at 9:28 a.m., and on 08/22/2026 at 1:54p.m., were unsuccessful. During an interview with LVN A on 08/22/2026 at 2:26p.m., she said she was trained on medication administration. She said the policy was medications had to be given within one hour before and one hour after the scheduled time. She said the staff member who was administering the medication was responsible for giving the medication to the residents on time. She said if medication was not given on time the resident could have a negative outcome. She said she did not know who monitored to ensure medication was given timely. She said that she did not give Resident #1 her medication late. She said she did not have time to document when she gave the medications. She said she thought the facility had enough staff for her to document the medications at the time given. During an interview with an FM of Resident #1 on 08/22/2026 at 3:02p.m., she said that Resident #1 was not getting her medications on time. She said when she visited she would get her medication late and would ask what the pills were and LVN A would not give her the information. During an interview with the DON on 08/22/2026 at 3:08 p.m., she said she was trained on medication administration. She said the policy was medication was to be given an hour before and an hour after the prescribed time. She said the nurses and the medication aides were responsible for ensuring the residents were getting their medication on time. She said if the resident was not given their medication on time; depending on what medication it could affect the resident's health because some medications cannot be given too close together. She said the DON and ADON monitored to ensure the residents were getting their medication on time. She said the DON and ADON monitored by pulling a report that shows what time the staff gave the medications and a report for any medications that were missed. She said she did not know why LVN A did not give Resident #1 her medication on time. During an interview with the ADM on 08/22/2026 at 5:37p.m., she said she was trained on medication administration. She said the policy was medication was to be given an hour before and an hour after the prescribed time. She said the nurses or medication aides were responsible for giving medication on time. She said if the medication was not given on time it could affect the resident by not being therapeutic to the resident. She said the ADON and DON monitored to ensure medication was given timely. She said the ADON and DON did this by auditing the MAR. She said LVN A told her she did not click that she gave the medication at the time she gave it. She said Resident #1 got her medication on time. Record review of the Administering Medications Policy, dated 04/2019, reflected Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frames. Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example, before and after meal orders).

Based on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for complete and accurate records. The facility failed to ensure LVN A documented medications at the time administered to Resident #1. This failure could place residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings include: Record review of Resident #1's face sheet, dated 08/22/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included Schizophrenia (mental disorder that affects a person's ability to think, feel and behave clearly), tinea Unguium (fungal nail infection), peripheral vascular disease (abnormal narrowing of arteries), hypertension (high blood pressure), hereditary and idiopathic neuropathy (nerve damage inherited from parent and unclear cause), Parkinson's disease (movement disorder of the nervous system that worsen over time) and anxiety (feeling of uneasiness or worry). Record review of Resident #1's admission MDS assessment, dated 05/06/2026, reflected Resident #1 had a BIMS score of 15, which indicated intact cognitive response. Record review of Resident #1's physician orders, dated 07/18/2026, Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease. Record review of Resident #1's Medication Administration Audit Report dated 08/22/2026 reflected Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease was to be given at 7:00a.m. on 07/30/2026 and Resident #1 did not get it until 2:14p.m. LVN did not document she gave the medication until 2:34p.m. on 07/30/2026 according to LVN A's documentation. Record review of Resident #1's Medication Administration Audit Report dated 08/22/2026 reflected Memantine Oral Tablet 10 MG (Memantine) Give 1 tablet by mouth two times a day for Parkinson's disease was to be given at 7:00a.m. on 08/18/2026 and Resident #1 did not get it until 8:46a.m. LVN A did not document the medication was given until 1:45p.m. on 08/18/2026 according to LVN A's documentation. Record review of Resident #1's Care Plan, dated 07/22/2026, reflected Focus: The resident is on anitParkinson therapy Memantine r/t Parkinson's disease.Goal: The resident will be free of any discomfort or adverse side effects of anitParkinson therapy through the review date.Interventions: Administer ANTI-PARKINSON'S medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. During an interview with LVN A on 08/22/2026 at 2:28p.m., she said she was trained on medication documentation. She said the policy for medication administration documentation was that staff were to document at the time the medication was given. She said the nurse was responsible for documenting medication at the time given. She said she did not know how it could affect the resident if medication was not documented at the time given. She said the DON monitored to ensure medication was documented when given. She said the DON monitored by checking the MARs. She said she did not have time to document at the time she gave Resident #1 her medications. During an interview with the DON on 08/22/2026 at 12:15 p.m., she said she had been trained on medication documentation. She said the policy for medication documentation was that the staff should be documenting in the MAR when the medication was given. She said the nurse or medication aide was responsible for documenting the medication when given. She said if staff did not document at the time medication was given it could cause the resident to get a double dose of medication and affect their health. She said the ADON monitored to ensure staff were documenting at the time medication was given. She said the ADON monitored by running a report that showed when the medication was given and what time it was documented. She said she did not know why LVN A did not document at the time she gave Resident #1's medication. During an interview with the ADM on 05/01/2026 at 1:45 p.m., she said she was trained on medication documentation. She said the policy for medication documentation was to document all medication given at the time it was given. She said the staff member who was giving the medication was responsible for documenting the medication at the time given. She said if staff did not document at the time medication was given it could cause the resident to get a double dose of medication. She said the DON and ADON monitored to ensure staff were documenting at the time medication was given. She said the DON and ADON monitored by checking the MAR. She said she thought LVN A did not document Resident #1's medication because she was in a rush. Record review of the Charting and Documentation Policy dated 07/2172 reflected The following information is to be documented in the resident medical record objective observations, medications administered, treatments or services performed, changes in the resident's condition, events, incidents, or accidents involving the resident, and progress toward or changes in the care plan goals and objectives. 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.

Based on observations, interviews, and record review. The facility failed to provide maintenance services necessary to maintain a comfortable interior for 3 of 16 Residents (Resident #6, Resident #21, and Resident #35) who were reviewed for a home-like environment. The facility failed to ensure that the walls of Residents #6, #21, and #35 rooms were free of scuff marks and paint damage.The deficient practice could place residents at risk of a clean and comfortable home-like environment Findings include: 1.Review of Resident #6's face sheet revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis, including Active primary, progressive, multiple sclerosis, dysphasia, Parkinson's disease, anxiety disorder, and muscle weakness. Review of Resident #6's quarterly MDS, dated [DATE], revealed the score of 12, reflecting she had moderate cognitive impairment. Resident #2 was functional and able to perform some of her ADLs. Review of Resident #6's care plan, dated 4/01/2026, revealed that the resident was at risk for falls with limited mobility. Interventions included the resident being totally dependent on one staff member to provide baths and showers. 2.Review of Resident #21's face sheet revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with a diagnosis, including Legal blindness, Type two diabetes, and morbid obesity. Review of Resident #21's quarterly MDS, dated [DATE], revealed the score of 15, reflecting her cognition is fully intact. Resident #21 was functional and able to perform some of her ADLs with limited assistance. Review of Resident #21's care plan, dated 5/08/2026, revealed that resident was at risk for falls with impaired mobility. Interventions included observing the environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery/cluttered floor surfaces, improper footwear, and failure to use assistive devices. 3.Review of Resident #35's face sheet revealed she was admitted to the facility on [DATE] with a diagnosis, including: Cerebrovascular Disease, Morbid (Severe) Obesity, and Alzheimer's Disease with late onset. Review of resident #35's quarterly MDS, dated [DATE], revealed the score of 15, reflecting that her cognition is fully intact. Resident #35 needs assistance with all of her ADLs. Review of resident #35's care plan, dated 2/24/2026, revealed that the resident #35 was The resident has an ADL self-care performance deficit. Resident #35 will receive assistance with bathing/showering, bed mobility, dressing, eating, toileting, and transfers. An interview and observation with Resident #21 on 06/09/2026 @ 8:57 AM. Resident #21 had several scuff marks and repairs in the room that have not been painted. Resident #21 stated that he has reported and nothing has changed. He stated that it bothers him and he would like the walls to be fixed. An Interview and observation with Resident #6 on 06/09/2026 at 9:20 AM - Resident #6 Walls are scuffed up and repaired behind the bed that was not painted. Resident #6 stated that the walls have been scuffed up for a while. He stated that he had told someone, but nothing was done. Resident #6 stated that the walls have been like that for a month. An interview and observation with Resident #35 on 06/10/2026 11:56 PM and daughter was in the room at the time. The daughter stated that the walls have a lot of damage. The daughter stated that she has mentioned this to the facility and nothing has been done, she stated that she does not feel like it is a homelike environment for the resident. The daughter stated that she wants the facility to address this issue. An interview on 6/11/2026 at 2:58 PM the MD stated that if there are any concerns with a residence room, there's an app they use to request things like painting or bathroom issues. She stated that once the request was made, maintenance will receive it and was responsible for fixing the issues. She stated she has not had any residents complain about the scuffed-up walls. She stated she had previously requested the walls be repaired. She stated if multiple requests are not completed, they are forwarded to the administrator. She stated residents with scuffed-up balls are not in a home-like environment. An interview on 6/11/2026 at 3:03 PM ADON stated if there was a maintenance request, she will go into the computer and enter it into the application. She stated the requests were sometimes made verbally. She stated that maintenance keeps track of all maintenance issues. She stated she has not heard any residents complain about the scuff marks on the paint in their rooms. She stated these should be repaired by maintenance. She stated if repairs are not made, residents would want to move to another room. She stated that having scuffed-up walls was not a home-like environment for the residents. An interview on 6/11/2026 at 3:24 PM the MD. She stated there are times when the floor staff does not make those requests, so they do not know what needs to be fixed. He stated that floor staff should make rounds in the rooms to ensure there are no issues and, if there are, submit those requests via the app. He stated it was either his responsibility or the maintenance assistant's responsibility to complete the repairs and residence rooms. He stated if repairs are not done for the residence, it will not have a home-like environment. An interview on 6/11/2026 3:40 PM with ADM. She stated there was an online portal where staff can submit maintenance and repair requests. She stated repairs are expected to be made in a timely manner. She stated staff should make rounds in the morning and, if repairs are needed, enter them into the online maintenance portal for completion. She stated a residence with scuffed-up walls was not a home-like environment. Record review of the facilities home like environment policy revise February 2021 reflected the following: The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include:a. clean, sanitary, and orderly environment.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents (Resident #12 and Resident #11) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #11 and Resident #12. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis PTSD (post-traumatic stress disorder) with an onset was present upon Resident #12 and Resident #11's admission. 2. The facility did not complete a 1012 form to update Resident #12 and Resident #11's PASARR Level 1 with the new diagnosis. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Resident #12Record review of Resident #12's face sheet indicated a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of bipolar disorder, current episode depressed, severe with psychotic features. On 4/27/2026, Resident #12 was diagnosed with bipolar type. Record review of Resident #12's MDS record dated 04/19/2026 revealed a BIMS score of 14, reflecting she had moderate cognitive impairment. Resident #12 had a diagnosis of bipolar disorder triggered at that time. Record review of Resident #12's care plan does not reveal Resident #12's mental illness. Record review of Resident #12's level 1 PASARR dated 04/21/2026 indicated that Resident #1 had no evidence of a primary diagnosis for this individual, individual had no mental illness, no intellectual disability and/or evidence that this individual has a developmental disability. Resident #11Review of Resident #11's face sheet revealed she was admitted to the facility on [DATE] and a readmission on [DATE] with a diagnosis, including: Progressive Multiple Sclerosis, Dysphagia, Oropharyngeal Phase, and Major Depressive Disorder, Recurrent Severe Without Psychotic Features dated 10/06/2025. Review of Resident #11's quarterly MDS, dated [DATE], revealed a BIMS score of 12, reflecting she had moderate cognitive impairment. MDS showed that Resident had Resident #11 has little interest or pleasure in doing things The MDS did not address her mental illness. Review of Resident #11's care plan, dated 3/03/2026, revealed that the resident was The resident has little or no activity involvement. The resident wishes not to Participate. The care plan did not address the mental illness. Establish and record the residents' prior level of activity involvement and interests by talking with the residents, caregivers, and family on admission and as necessary. Record review of Resident #11's level 1 PASARR dated 04/11/2026 indicated that Resident #1 had no evidence of a primary diagnosis for this individual, individual had no mental illness, no intellectual disability and/or evidence that this individual has a developmental disability. An interview on 6/11/2026 at 3:45 PM the MDS coordinator stated that residents get a PASRR prior to admission to the facility. She stated that if a resident were to have a new diagnosis, that would trigger a new PASARR assessment. She stated that after a positive PASARR assessment, someone from outside the facility would come to administer a PASARR 2 assessment. She stated that if a resident does not get an updated PASARR assessment, then they could miss out on services. She stated that Resident #11 should have received another PASARR assessment after her diagnosis of major depressive disorder on 10/06/2026. An interview on 6/11/2026 at 4:08 PM the DON stated that the MDS coordinator was the one responsible for updating the PASRR Screenings. She stated that residents with a new diagnosis should receive a new PASRR screening to determine eligibility for services. She stated that they conduct a PASARR assessment to ensure they are all up to date. She stated that if the PASRR is not up to date then a resident misses out on services. She stated that Resident #11 should have had a new assessment after the diagnosis on 10/06/2026. An interview on 6/11/2026 the ADM said the MDS coordinators are responsible for updating the PASARR screenings. She stated that if the PASARR screenings are not up to date, then a resident could go without services. She stated that if a resident was diagnosed on [DATE], then the resident should have had a new PASARR screening after the new diagnosis. Record review of facility provided policy titled PASARR dated 01/20/2026 indicated the following: Purpose: The aim of the PASARR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in the community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD.

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents (Resident #81 and Resident #67) reviewed for PASARR Level I screenings. 1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #81 and Resident #67. The PASARR Level 1 screening indicated a negative level 1 despite the resident had a diagnosis prior to the PASARR being completed. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs. Findings included: Resident #81Record review of Resident #81's face sheet indicated a [AGE] year-old female readmitted to the facility on [DATE] with diagnoses of bipolar disorder and depression. Record review of Resident #81's care plan dated 06/24/2025 revealed that Resident#81 was at risk for depression and takes an antidepressant. Resident #81's care plan indicated resident had a diagnosis of bipolar disorder and depression. Record review of Resident #81's level 1 PASARR dated 03/01/2025 indicated that Resident #81 had no evidence of a primary diagnosis for mental illness. Resident #67Review of Resident #67's face sheet indicated an [AGE] year-old man admitted to the facility on [DATE] with diagnoses of schizophrenia. Review of resident #67's care plan dated 06/26/2025 revealed that Resident #67 had diagnoses of major depressive disorder and schizophrenia.Record review of Resident #67's level 1 PASARR dated 01/11/2022 indicated that Resident #67 had no evidence of a primary diagnosis for mental illness.An interview on 6/11/2026 at 3:45 PM the MDS coordinator stated that MDS was responsible for the PASARR screenings. MDS coordinator stated that a diagnosis such as schizophrenia would indicate a positive level 1 screening. MDS coordinator stated that if the PASARR screen was inaccurate, the residents could miss out on needed person-centered services. MDS coordinator stated that the PASARR screening for both Resident #81 a Resident #67 should have triggered positive due to the diagnosis of schizophrenia and bipolar disorder and would be considered inaccurate. An interview on 6/11/2026 at 4:08 PM with the DON stated that the MDS coordinator was the one responsible for updating the PASARR Screenings. The DON stated that PASARR level 1 should be completed upon admission to the facility. The DON stated that bipolar disorder and schizophrenia are diagnoses that would trigger a positive level 1. The DON stated that if the PASARR screen was inaccurate, the residents could miss needed mental health services or experience a delay in receiving specialized services. The DON indicated that the screen was inaccurate. An interview on 6/11/2026 at 4:30PM the ADM stated that the MDS coordinators are responsible for updating the PASARR screenings. The ADM stated that diagnosis of bipolar schizophrenia would indicate a positive Level 1 screen. The ADM stated that if the PASARR was inaccurate, the residents may not have had the appropriate screening completed. The ADM stated that both Resident #81 and Resident #67's diagnosis would indicate a positive level 1 diagnosis and was an inaccurate screen. Record review of facility provided policy titled PASARR dated 01/20/2026 indicated the following: Purpose: The aim of the PASRR program is to identify residents with Mental Illness (MI), Intellectual Disability (ID) or Developmental Disability (DD)/Related Conditions (RC) and to ensure they are properly placed, whether in the community or in a Nursing Facility (NF) and to ensure they receive the services they require for their MI, or ID/DD.

Based on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food Service safety, for one of one kitchen reviewed for food storage. The facility failed to label and date food correctly. These failures could place residents at risk for foodborne illnesses. The findings include: An Observation on 06/09/2026 at 6:50 AM of the walk-in refrigerator revealed the following: Cubed raw potatoes in a Ziploc bag with an open date 6/3/2026 and no use-by date. Chicken tenders in a Ziploc bag with no open date and no use-by date Daily milkshake in a serving jug with an open date of 6/8/2026 with no use-by date. An observation on 06/09/2026 at 6:55 AM of the walk-in freezer revealed the following: Sugar cookies in a Ziploc bag with an open date of 5/19/2026 and no use-by date. An observation on 6/9/2026 at 6:59 AM of the pantry revealed the following: Black Eyed Peas in a Ziploc bag with an open date of 5/24/2026 with no use-by date. Fritos chips and a Ziploc bag with no open date or use by date on the bag. An interview on 6/11/2026 at 2:05 PM CK stated she has been working at the facility for seven months as the cook. She stated it was everybody's responsibility to label and date food items in the kitchen. She stated that food items in the kitchen should be checked daily for dating. She stated all food items should have an open date and be used by the day. She stated they use the first-in, first-out method, which means all the old items go in front and the new items go back. She stated they usually have a daily huddle to discuss labeling and dating food items in the kitchen. She stated that if residents were served out-of-date food, they could get sick. An interview on 6/11/2026 at 2:13 PM DA stated she has been working at a facility for seven months. She stated that everybody in the kitchen was responsible for labeling and dating food items. She stated that she labels and dates certain items in the kitchen, and the cook labels certain items there. She stated the cooks normally label leftovers. She said she usually labels and dates juices and items to be served the same day. She stated they use the first-in, first-out method, where when they get a truck, the old items go in front, and the new items go back. She stated she has had in-service training on labeling and dating. She stated her last in-service training was on 6/9/2026. She stated that if residents are served out-of-date food, they could get sick. An interview on 6/11/2026 at 2:20 PM DM stated that everyone in the kitchen was required to label and date all food items they handle. She stated that she and the cooks should be checking daily for out-of-date food items. She stated they use the first-in, first-out method, where they place old items at the front and new items at the back, so the old items are used first. She stated they do not check the dry goods daily, mainly the food in the walk-in cooler. She stated she has been in service on labeling and dating. She stated the last time she had in-service training was two days ago. She stated that residents could get sick if they ate out-of-date food. An interview on 6/11/2026 at 4:26 PM ADM stated it was the responsibility of the whole dietary team to label and date food items in the kitchen. She stated that food items should be checked daily for out-of-date items and to make sure all items are labeled and dated. She stated an in-service was done two days ago for labeling and dating. She stated in-service training should be done with staff regularly so they are aware that all food items should be labeled and dated. She stated if residents were to eat at a date food they could get sick. Record review of the facilities, food, and storage policy updated November 2022 Reflected the following: All food items to be kept at or below 41 F are placed in the refrigerator located at the nurses' station and labeled with a use by date. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date). Such foods are rotated using a first in - first out system. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).

Based on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 3 of 8 residents (Resident #1, Resident #2, and Resident #3) reviewed for ADL care. The facility failed to ensure Resident #1 was provided with ADL care and repositioned timely per Resident #1's care plan The facility failed to ensure Resident #2 was assisted with ADLs timely. The facility failed to ensure that Resident #3 was assisted with incontinent care timely. This failure could place residents at an increased risk of not receiving services or care, diminishing quality of life, and decreased self-esteem. Findings included: 1.Record review of Resident #1's face sheet, dated 05/09/2026, reflected a [AGE] year-old-female originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included myoneural disorder (conditions that impair the communication between nerves and muscles, causing muscle weakness, fatigue, and potential respiratory issues), bacterial pneumonia (a serious lung infection that causes inflammation in the air sacs, filling them with fluid or pus), end stage renal disease on hemodialysis (permanent kidney failure requires dialysis or a transplant to sustain life), and vascular dementia (a decline in thinking skills caused by conditions that block or reduce blood flow to the brain, depriving brain cells of oxygen and nutrients). Record review of Resident #1's admission MDS Assessment, dated 02/01/2026, reflected Resident #1's BIMS 11, moderate cognitive impairment and triggered care areas reflected: urinary incontinence and pressure ulcer. Record review of Resident #1's Comprehensive Care Plan, dated 04/30/2026, reflected focus: The resident has pressure ulcer Right heel, Left heel or potential for pressure ulcer development related to immobility. Bladder and bowl incontinence: personal hygiene - requires substantial/maximal assistance. Record review of NP B wound care notes, dated 02/11/2026 at 7:04 p.m., revealed Resident #1 is incontinent of urine and stool and is at an increased risk of skin breakdown. Recommend continuing ongoing interventions and protocol for incontinence management. Recommend preventive barrier cream. The patient was noted to have dry skin generalized to entire body. Record review of nursing notes for Resident #1, dated 02/17/2026, revealed skin issue: Right ischium (the lower and back part of the hip bone): Moisture associated skin damage. Wound acquired in-house. It is unknown how. Record review of order summary report for Resident #1, dated 05/10/2026, revealed an order for excoriation right buttock: clean with normal saline, pat dry, apply zinc barrier cream twice every shift ordered on 03/24/2026. Record review of Resident #1's nursing progress notes, dated 04/03/2026, reflected Resident is one person assist with ADL's and brief changes. Resident is incontinent of bowel and bladder. Record review of Resident #1's TN's notes, dated 04/28/2026, revealed new skin issue: location - buttocks - generalized. Laterally/orientation. Right. Issue type: excoriation (scrape, scratch, or wearing away skin, resulting in an abrasion, raw lesion, or sore) wound. Painful: yes. Record review of Resident #1's hospital records with Emergency Department admission wound care scans, dated 05/04/2026, revealed pressure injury of right heel, unstageable with surrounding deep tissue pressure injury, pressure injury left heel with characteristics of deep tissue pressure injury, pressure injury sacrum (a large triangular bone situated at the base of the spine) characteristics of DTPI, Pressure injury right buttock. Characteristics of DTPI. Bilateral (both) feet pressure ulcers stage III (a severe, full-thickness skin loss extending into the subcutaneous fat tissue) extensive nonhealing, poor candidate for surgical intervention at her age and continue on wound care. She had multiple pressure injuries, including unstageable and deep tissue injuries on the heels, toes, sacrum, buttocks, and elbows, managed with wound care protocols.She demonstrated severe muscular deconditioning and required maximum assistance for all ADLs and functional mobility. Resident #1 was sent to the hospital due to the fever and change of condition. Observation and interview on 05/09/2026 at 7:00 p.m. revealed Resident #1 was lying in bed at the hospital with nursing staff charting in Resident #1's room. Resident # 1 was observed with wound dressings to her bilateral heels Resident #1 was unable to comprehensively answer questions regarding her care at the facility. Observation of call light responses on 05/09/2026 between 4:30 p.m. - 7:00 p.m. for Resident #2 and Resident #3 and 05/10/2026 between 8 a.m. and 2 p.m. for Resident #2 and Resident #3 revealed multiple call lights were answered between 30 mins and 1.5 hours' time period for multiple residents on 500, 600, 400 and 800 halls. During an interview on 05/10/2026 at 10:20 am, the RP of Resident #1 stated she did not trust the facility and felt that they did not provide good care to Resident #1. She stated that every time she came to see Resident #1 she had to wait for at least 45 minutes to an hour.to get help to Resident #1. She stated that Resident #1 was not repositioned every two hours while she was visiting at the facility on multiple occasions and that was why she got those pressure sores. She thought the facility did not have sufficient staffing to assist with ADL care to Resident #1. During an interview on 05/11/2026 at 12:05 p.m., LPN A stated she worked the 500 and 600 halls during day shift for (6 a.m. to 6 p.m.) for the last 3 years and took care of Resident #1. She stated that skin check assessments popped up on the MAR every week with different dates depending on the residents' admission dates. She stated she was not sure what day of the week the skin assessment was for Resident #1, but she did her skin assessments on regular basis, weekly. She stated that she initially saw pressure sores on Resident #1's bilateral heels about 3 weeks ago. She stated that Resident #1 normally wore soft boots while in bed for wound prevention, but she did not want to wear heel protecting boots due to pain or discomfort and did not wear them for two days when she noticed DTPI. She stated that Resident #1 developed those pressure sores due to staying in bed too long even nursing staff repositioned her every two hours per order. LPN A stated that they had an order for moister protective cream application to Resident #1's bottom, but Resident #1 did not have any skin openings on her bottom, elbows and heels. She stated that Resident #1 had some blanchable redness (a reddened area of the skin that temporarily turns pale or white when you press your finger on it and then quickly returns to red when the pressure is released) with some skin excoriation (red or irritated patches with visible linear marks or scabs) on her bottom and purplish DTPI on both heels. She stated that she communicated the finding to the doctor, sending her a picture and the wound care nurse was providing wound care for the resident. LPN A stated that Resident #1 had dialysis 3 times a week and did not want to get up on other days because she was tired. She stated that Resident #1 was totally dependent on staff to reposition her and assist with ADL activities like feeding and perineal care. She stated that she rounded on all 25 residents every 2 hours. She stated that recently they had 4-5 CNAs per 4 hallways which was enough staff to answer call lights promptly and attend to residents' needs in the timely manner. She stated that it could be difficult sometimes with acute residents that required a lot of attention, but she felt like she could handle that load. She stated sometimes they did not get medication aides and nurses had to pass medications to residents which put extra pressure on charge nurses. She stated that answering call lights was everybody's responsibility and she did not feel that Resident #1 was neglected. She stated that wound care nurse was notified, wound care NP and family nurse practitioner were notified immediately and wound care treatment ordered and provided by facility. She stated that Resident #1 was not eating well over weekend and started feeling worse on Monday morning and she contacted NP A immediately to get new orders and received an order to send Resident #1 to the hospital. During an interview on 05/10/2026 at 2:26 p.m., the TN stated that charge nurses were responsible for weekly skin assessments and reporting to her any issues. She stated that Resident #1 did not have any issues before 04/28/2026 and when it was reported to her on 04/28/2026, she assessed her and got an order from NP B for wound care treatment. She stated that she could not tell if the DTPIs were related to not being repositioned or due to trauma. She stated that she was not aware of any redness on Resident #1's bottom. She stated that everybody was responsible for answering call lights and she was not aware of any issues with attending to residents in the facility. During an interview on 05/09/2026 at 05:26 p.m., NP B stated she assesses residents in this facility weekly when received a wound referral and Resident #1 was referred for wound care as soon as unopened and unknown nature DTPI was identified on her both heels. She did not see this resident before her hospitalization due to Resident #1 was out of facility in dialysis. She stated that every 2 months she performed skin assessment for every resident in this facility and Resident #1 did not have any issues in March 2026 when she saw her last time. 2.Record review of Resident #2's face sheet, dated 05/10/2026, reflected a [AGE] year-old-female admitted to the facility on [DATE] with diagnoses which included hypertensive heart disease (structural and functional heart damage caused by chronically high blood pressure), non-pressure chronic ulcer (wound) of buttock limited to breakdown of skin, depression, and pain. Record review of Resident #2's MDS Assessment, dated 03/15/2026, reflected Resident #2's BIMS score of 15 which indicated intact cognition and frequently incontinent of bladder and always incontinent of bowel required substantial/maximal assistance when helper does more than half the effort for toileting hygiene and shower/bath. Record review of Resident #2's Comprehensive Care Plan, revised 03/31/2026, reflected focus: ADL self-care performance deficit related to limited mobility. Incontinent of bowel and bladder required x2 max assistance with ADLs and transfers with Hoyer lift (a mechanical device used by caregivers to transfer individuals with limited mobility between surfaces) x2 assistance. Resident #2 is totally dependent on x2 staff for incontinent care. Does not use toilet. Encourage the resident to use bell to call for assistance. Problematic manner in which resident acts characterized by ineffective coping. Agitation related to refuses care from staff and states the aides don't do her care the way she wants them to do her care. Record review of order summary report Resident #2, dated 05/10/2026, revealed an order for Bacitracin external ointment 500 unit/GM/Apply to Right buttock topically one time a day related to non-pressure chronic ulcer of buttock limited to breakdown of skin with the start date 04/15/2026. Abscess right buttocks: clen with normal saline, pat dry, apply bacitracin ointment daily and as needed and leave open to air one time a day.Record review of progress notes signed by NP B, dated 04/29/2025, revealed Resident #2 was at high risk for pressure ulcer formation related to decreased mobility, comorbidities, history of a previous pressure injury, incontinence of urine and stool. Patient has a moderate to severe risk of significant complications related to wound healing, morbidity, and overall mortality due to comorbidities. Use appropriate moisture barrier creams per approved list to provide thorough skin care.Keep patient off bottom as resident will allow; turn patient side to side as tolerated. Continue with turning and repositioning schedule per protocol for pressure prevention. Record review of toileting hygiene documentation for Resident #2, dated 04/11/2026 - 05/10/2026, revealed the documentation of assisting Resident #2 with toileting (dependent - helper does all of the efforts or partial (helper does less than half the efforts) only once a day: 4/12/20264/14/2026, 4/21/2026, 4/25/2026, and 4/28/2026. During interview on 05/10/2026 at 9:25 a.m., Resident #2 stated she had issues with the call light answering time, often 45minutes to 2 hours wait time. She stated that she has a cell phone she can monitor her wait time on. She stated that she wanted to be up in her wheelchair by now and she had been waiting for nursing staff to assist her with getting up She stated that she notified staff about wanting to get up and they told her they will come, but it was 2 hours and they did not come. She stated that she required a Hoyer lift for transferring from bed to wheelchair. She stated that she wanted to be back in bed by 4:00 p.m. and get assistance with the bed pan and cleaning but she had to wait for somebody to get her back to bed for a while. The resident stated one time the Hoyer lift batteries were all dead in the whole facility, and they could not get her back to bed. She stated nursing staff told her to wait, but she had pain 10/10 in her bottom and could not wait any longer. She called 911 and local firefighters came and assisted her back to bed. She stated that it made her feel sad and she could not stand the pain sitting in chair and waiting for too long. During an interview on 05/10/2026 at 10:20 am, CNA C stated she worked with Resident #1, Resident #2 and Resident #3. She stated that she was able to round on all residents that required incontinent care task. She stated she did not recall these residents complaining of not being changed or having skin issues. She stated that she was taking care of 15-18 residents on different halls if nobody called in and felt like she was able to provide good care for those residents. She stated that she did not recall the Hoyer lift not working to get Resident #2 to bed. CNA C stated that not rounding on residents every two hours and not assisting them with incontinent care or showers could lead to neglect and skin problems. During an interview on 04/10/2026 at 10:40 am, LPN E stated she worked as a charge nurse on day shift (6 a.m. -6 p.m.) on 400 hall. She stated she worked with Resident #2 and provided her with care she required. She stated that CNAs were responsible for providing residents' incontinent care and showers but charge nurses assisted them as needed. She stated if a can observed any problems with a resident's skin during peri care or showers, they were to report it to charge nurse using shower sheets for documentation. She stated she had been in-serviced on incontinent care and rounding time, every 2 hours. She stated that sometimes it was hard to attend to every resident timely due to volume of work and acuity of residents. 3.Record review of Resident #3's face sheet, dated 05/10/2026, reflected 78 years-old-female initially admitted on [DATE] and readmitted on [DATE] with diagnoses which included gastro-esophageal reflux disease (a chronic digestive condition where stomach acid repeatedly flows back into the esophagus), cellulitis of left upper and lower limbs (a common, potentially serious bacterial infection of the deep layers of the skin and underlying tissues), depression, and type 2 diabetes mellitus (a chronic condition where the body resists the effects of insulin or doesn't produce enough to maintain normal glucose levels). Record review of Resident #3's quarterly MDS dated [DATE] reflected a BIMS score of 13 indicating her cognition was intact and always incontinent for bowel and bladder. Record review of Resident #3's care plan, dated 03/31/2026, reflected that he had an ADL self-care performance deficit related to activity intolerance, fatigue and impaired balance. The relevant intervention was one staff assistance with personal hygiene and oral care. Record review of Resident #3's progress notes, dated 05/10/2026 and signed by RN B, revealed Resident #3 had a new skin issue. Location: buttocks - generalized. Laterality/Orientation: inferior. Issue type: Moisture associated skin damage. Incontinent associated dermatitis (skin inflammation). Wound acquired in-house. Length: 10 centimeters - Width: 10 centimeters. Resident has non-opened redness to the inferior (lower) buttock bilaterally (both buttocks). Affected area is being cleaned and dried throughout shift. No signs of opening or drainage present. Resident has no other skin related concerns at this time. Resident is incontinent of urine. Resident uses adult briefs. Observation of call light for Resident #3's room for 48 minutes from 9:11 a.m. - 9: 59 a.m. revealed nursing staff passing by and not attending to Resident #3's call light. Resident #3 was observed lying in bed with a breakfast tray in front of her. During an interview on 05/10/2026 at 10:10 a.m., Resident #3 stated that nobody checked on her last night and she had a wet incontinent brief part of the night. She stated the CNA came this morning to change her and the only brief they had available was too small for her, so she waited for a few hours to get the right size brief. She stated that she asked her RP to bring incontinent briefs for her that fit her as incontinent briefs at the facility are too small. She stated that it bothered her that she waited too long to be assisted with changing her wet brief on different shifts. She stated that it happened over different shifts: night and days. She stated that no specific nursing staff that she could name don't attend to her. Attempted to contact Resident #3's RP on 05/10/2026 at 10:34 a.m. to confirm Resident #3 statement regarding incontinent brief supply was unsuccessful. Observation of Resident #3's brief on 05/10/2026 at 10:21 a.m. revealed a moderately wet incontinent brief without signs of being too small and uncomfortable to Resident #3. During an interview on 05/10/2026 at 10:51 p.m., CNA F stated that she started a month ago working the day shift on 700 and 800 halls. She stated that she rounded on residents every two hours and was assisting Resident #3 with incontinent care and she could not find the right size brief this morning, but RN B brought incontinent briefs and now she had it. She stated that she had in-service on answering call lights as soon as possible. She stated that she did not see the call light for Resident #3 being on for that long. She stated that not assisting resident who need incontinent care or answering call lights could lead to falls and residents being upset. During an interview on 04/10/2026 at 11:10 a.m., RN B stated that he worked as a charge nurse during day shift on 700 and 800 halls. He stated that CNAs and charge nurses were responsible for rounding on residents every 2 hours and assisting them with incontinent care as needed. He stated that he rounded on Resident #3 today several times. He stated he was able to provide high quality care to residents, but it was challenging sometimes if only 3 CNAs were scheduled for 4 hallways During an interview on 05/10/26 at 2:15 p.m., the DON stated that CNAs were responsible for providing incontinent care to residents promptly and checking on residents every two hours. She stated that Resident #1 was assessed for skin issues on the weekly basis by charge nurses and wound care nurse was providing her with wound care treatment daily. She stated that she assessed Resident #1 herself on the day she was sent to the hospital when she was informed about Resident #1 not eating and increased fever. She explained that Resident #2 was particular about how the tasks were performed and that she often refused being assisted by certain staff and requested only one particular nursing staff to assist her with incontinent care or transfers which was care planned in Resident #2's care plan. She stated that they have manual Hoyer lift and Resident #3 did not want to use it. She stated that answering call lights was everybody's responsibility and if residents who required assistance left unattended could affect their skin integrity. She stated that they had enough nursing staff attend to residents and provide them with good care. The DON stated that she did not think Residents #1, 2 and 3 were neglected. During an interview and observation on 05/10/2026 at 2:21 p.m., the ADM stated she worked at this facility as administrator for 3 years. She stated the facility was fully staffed and they did not have any issues with short nursing staff including CNAs and nurses to provide the care to residents. She stated that answering call lights depended on the situation and potentially answering call lights within 1 hour was reasonable if nursing staff was busy addressing an emergency situation. She stated that there was no set rounding time on residents but residents should be assessed and checked by staff on regular basis. She stated that residents who complained about not being checked and assisted on the timely matter were lying to get the facility in trouble. The ADM stated that residents were supposed to be repositioned according to physician's orders within 2 hours by CNAs or nurses. She stated that Resident #2 wanted special treatment from the staff, refusing to be transferred by certain staff and they could not provide her special treatment. She stated that they had two batteries charged on nursing station 1 and two Hoyer battery charged on nursing station 2. The ADM stated, If there is ever an instance where the battery-operated Hoyer lifts were not working, we have 2 manual Hoyers that can be utilized. The internal batteries for the Hoyers get replaced as needed. She stated that all residents at the facility were fitted for right size of incontinent briefs and they had invoices confirming ordering and receiving enough supplies for residents at the facility. She demonstrated the supply closet with briefs on the shelves which was observed by surveyor. Record review of grievances for 3 months (February -April 2026), revealed multiple concerns on not answered call lights and Waiting to get changed. Record review of the facility policy Activities of daily living (ADL), supporting, revised in March 2018 and updated February 2025, reflected: Residents will be provided with care, treatment and services as appropriated to maintain or improve their ability to care out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: Hygiene (bathing, dressing, grooming, and oral care);Mobility (transfer and ambulation, including walking);Elimination (toileting); If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time or having another staff member speak with the resident may be appropriate.Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. Record review of facility policy Call System, Residents, revised in September 2022 and updated in January 2025, reflected Residents provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. 6. Calls for assistance are answered timely.

Based on observation, interview, and record review the facility failed to ensure residents are given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 2 of 5 residents (Resident #1 and Resident #2) reviewed for hygiene. The facility failed to ensure Residents #1 and Resident #2 were provided with care and services for hygiene. This failure could place residents at risk for poor self-esteem, infections, socialization, ADL decline and diminished quality of life.Findings included: Record review of Resident #1's face sheet dated 3/31/26 revealed a [AGE] year-old female who was admitted into the facility on 2/1/2026 with an initial admission date of 2/22/2023. Resident #1 was diagnosed with type 2 diabetes mellitus with circulatory complications (various cardiovascular issues that can arise due to poorly managed diabetes, significantly increasing the risk of serious health problems), acute combined systolic (congestive) and diastolic (congestive) heart failure (a serious condition where the heart cannot pump enough blood, requiring immediate medical attention), nondisplaced trimalleolar fracture of unspecified lower leg, sequela (a fracture involving the three malleoli of the ankle: the medial malleolus (fibula), lateral malleolus (fibula), and posterior malleolus (tibia), chronic kidney disease, stage 3B (a moderate to severe loss of kidney function, with an estimated glomerular filtration rate (eGFR), edema, unspecified (swelling caused by fluid accumulation in body tissues without a clearly identified underlying cause). Record review of Resident #1's quarterly MDS, dated [DATE] revealed; Resident #1 had a BIMS score of 15, which indicated cognitively intact. Record review of Resident #1's care plan last updated 2/26/26 revealed no focus or intervention addressing Resident #1 history of refusing showers. Resident#1 reflected Focus: ADL self-care performance deficit r/t limited mobility. Goal: Resident #1 will maintain current level of function. Interventions: Bathing/Showering Resident # will be provided sponge bath when a full bath or shower cannot be tolerated. The resident is totally dependent X1 staff to provide bath/shower. Record review of Resident #1's shower sheet dated 3/3/2026 to 3/31/2026 reflected:03/03/2026 @ 12:59 PM Yes03/05/2026 @ 17:59 PM Yes03/07/2026 @ 1:25 PM and 23:30 PM Not Applicable03/09/2026 @ 00:30 AM Yes03/10/2026 @ 00:02 AM Yes03/11/2026 @ 01:50 PM and 22:43 Not applicable03/12/2026 @ 14:37 PM and 22:31 PM Yes03/13/2026 @ 20:28 PM Not Applicable03/14/2026 @ 23:36 PM Not Applicable03/15/2026 @ 17:59 PM Resident Refused and 22:04 Not Applicable 03/16/2026 @ 12:59 PM Yes03/17/2026 @ 22:02 PM Yes03/18/2026 @ 23:55 PM Yes03/19/2026 @ 23:27 PM Yes03/20/2026 @ 15:05 PM Yes03/21/2026 @ 22:13 PM Yes03/22/2026 @ 20:14 PM Not Applicable03/23/2026 @ 17:59 PM No03/24/2026 @ 17:59 PM Resident Refused03/26/2026 @ 17:59 Yes03/28/2026 @ 17:59 PM Resident Refused03/31/2026 @ 16:04 PM Not Applicable During an interview with Resident #1 on 3/31/2026 at 4:10 pm, she stated she has not had a shower since last Tuesday 3/24/2026. She stated she did not refuse showers. She stated they tell her sometimes they were short and they cannot give her a shower. She stated sometimes she has denied taking a shower if she was in too much pain or had a doctor's appointment. The resident stated her shower days were Tuesdays, Wednesdays, and Saturdays. Resident was observed without an odor as she stated she gets a bed bath in between showers. She was dressed in a dress that appeared to be clean. Record review of Resident #2's face sheet dated 03/31/2026, revealed Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #2 was diagnosed with acute systolic (congestive) heart failure (a long-term condition that happens when your heart can't pump blood well enough to give your body a normal supply), type 2 diabetes mellitus with other diabetic kidney complication (the condition where prolonged high blood sugar levels lead to kidney damage, commonly known as diabetic nephropathy), legal blindness, as defined in USA (having a best-corrected visual acuity of 20/200 or worse in the better-seeing eye, or a visual field of 20 degrees or less.), epilepsy, unspecified, not intractable, without status epilepticus (characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain). Record review of Resident #2's quarterly MDS, dated [DATE] revealed; Resident #2 had a BIMS score of 15, which indicated cognitively intact. Resident #2 has the ability to bathe self. Including washing, rinsing, and drying self (excluded washing of back and hair). Does not include transferring in/out of tub/shower. Record review of Resident #2's care plan dated 03/09/26, revealed Resident #2 had an ADL self-care performance deficit r/t Limited ROM, Resident #2 is non-compliant with showers at times. Interventions: Resident can bathe herself. Record review of Resident#2's shower sheet dated 3/3/2026 to 3/21/2026 reflected:03/03/2026 @ 17:59 PM Yes03/04/2026 @ 21:00 PM Yes03/05/2026 @ 17:59 PM Yes03/07/2026 @ 1:56 PM and 23:33 PM Not Applicable03/09/2026 @ 00:37 AM Yes03/10/2026 @ 00:06 AM and 00:07 AM Yes03/11/2026 @ 00:06 AM Yes and 17:59 Yes03/12/2026 @ 15:00 PM Yes, 15:01 PM Yes, 22:49 PM Yes, 22:50 PM Yes03/13/2026 @ 20:44 PM and 20:45 PM Not Applicable03/14/2026 @ 23:36 PM and 23:37 PM Not Applicable03/15/2026 @ 22:06 PM Not Applicable 03/16/2026 @ 17:59 PM Yes03/17/2026 @ 17:59 PM Yes and 22:55 PM Resident Refused03/18/2026 @ 21:53 PM Yes03/19/2026 @ 23:32 PM and 23:34 PM Yes03/20/2026 @ 21:14 PM and 21:15 PM Not Applicable03/21/2026 @ 21:46 PM Not Applicable During an interview with Resident #2 on 04/01/2026 at 11:20 am, she stated she was not getting showers like she was supposed to. She stated there was one lady that works at night that makes sure she received her showers and her hair was washed. She stated she will wash herself in the sink in the bathroom. She stated she refused a shower once because she had an appointment, but she stated once she returned, she would take her shower, but no one ever said anything once she returned. She stated she was supposed to get a shower today 3/31/2026. Resident # 2 did not have any foul odor. She was dressed appropriate for the weather. Her shower days were Tuesdays. Thursdays, and Saturdays. During an interview with Med Aide A, on 3/31/2026 at 5:17 PM she stated they make rounds every 2 hours, but they answer the call lights. She stated when she was working, she sees the aide's giving showers to the residents, but sometimes the residents refused. She stated the nurses were supposed to be charting. The aides were supposed to let the nurses know so the nurses can make sure the refusals were charted. She stated she wasn't really on the floor to give showers. She stated she will work on the med cart before going on the floor. She stated she has brought people in to just focus on showers. She had one resident whose family member wanted to know when they give showers, and she stated she told the ADON. She stated the staff marks shower sheets when they give out showers, or they just write resident refused. She stated staff just have not been checking the resident refused in the electronic health records. During an interview on 4/1/2026 at 1:53 PM with the ADM, she stated they cannot force the residents to take a shower because it was their right. She stated it was care planned that the resident refused showers. She stated the goal was to give them a shower once a week. The ADM stated the scheduled staff will attempt to give the resident a shower, and if they cannot, they will try with a particular person they like to give it to them. If that does not work, they will have family get involved. During an interview on 4/1/2026 at 2:25 PM with the DON, she stated her expectations of her nurse aides was to provide showers and ADL care to the residents and also chart. She stated a lot of the residents refused showers. The DON stated she was asking the residents to agree to take a shower at least once a week. She stated it will be care planned and let the family know. The DON stated the resident will receive bed baths or a wash up. She stated they cannot go past a week without a shower because it could cause skin breakdown, they will start to smell, and they can get an infection. She did not know why the staff was charting refusals in the electronic health system, but they did have shower sheets. Record review of the Activities of Daily Living policy dated February 2025 revealed Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary tomaintain good nutrition, grooming and personal and oral hygiene. 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. hygiene (bathing, dressing, grooming, and oral care).

Based on observation, interview, and record review the facility failed to ensure food and drink that is palatable, attractive, safe and appetizing temperature for residents in the 1 kitchen of 1. The facility failed to ensure residents received food that tasted good. The facility failed to ensure residents did not receive cold food. The facility failed to prepare enough food to ensure all residents received the meals offered. These failures could place residents on regular diet and puree diet at risk of receiving inadequate diet that could affect their health and unwanted weight loss. Findings included: Observation on 3/31/2026 at 11:30 am, the Surveyor entered the kitchen and observed staff preparing meal trays for residents in the facility. The Surveyor asked the [NAME] where the temperatures were, she had taken prior to beginning to prepare lunch trays, and she said she had not gotten around to writing them down, but she remembered them for all the meals. The Surveyor observed the lunch meal for the of 3/31/2026 was beef stroganoff over egg noodles, green beans with pimento, dinner roll and gooey butter bar. During the observation, Surveyor observed the cook came to the last 5 trays and there was no more food prepared to complete the trays. The dietary manager and other staff in the kitchen chopped up some hamburger patties and mixed some gravy in it and placed it over the noodles to complete the remaining 5 meal trays. Surveyor observed there were not enough dinner rolls for all residents. The staff cut bread in half to substitute for the residents missing a dinner roll. A test tray was not requested as there was not enough food prepared for the residents. A test tray would have been the made-up meal they put together at the last minute. Record review of the grievances revealed resident had complained about the food being cold and the kitchen does not prepare enough food. Interview on 3/31/2026 at 2:03 PM, the DM stated more food should have been cooked. She stated it was not often they do not prepare enough food. She stated she will educate on portion size to prevent shortage of food. The DM stated to prevent shortage, she will have them prepare additional food by increasing the recipe. The DM stated the temperatures for the hot plates should be at least 130. The hot plates were not warm/hot to touch. She stated the staff should take the temperature on the food line about 15 minutes before serving. The DM stated the residents were given slips of what will be served for the different meals. The residents determine if they want what was prepared or if they want an alternative meal. She stated she expected her staff to follow guidelines. Interview on 3/31/2026 at 2:46 PM, CK A stated her responsibility was to prepare the meals for the different diets and maintain the temperatures of the food once it was prepared. CK A stated she takes the temperatures when she puts the food on the stem table. She stated she measures the amount of food needed based on what the packaging tells her. She stated they followed the recipe according to what the book tells her. CK A stated she believed they received the menus from corporate. CK A denied running out of food. She stated she had hamburger meat to add to what she had already prepared. She stated she normally has leftovers. She stated about twenty of the residents will choose the alternate menu and she tries to accommodate them. CK A stated no resident will ever go to bed hungry. She stated her rule was if someone comes to the door and asked for something, she will offer them something until they leave with something. Interview on 3/31/2026 at 1:53 PM, the ADM stated she expected the resident to get what they asked for and not the alternative meal unless they asked for it. She stated to her understanding; they were able to make more. The ADM stated they normally had the base of the meal already prepared and if they need to, they can just make up the meal. As of 3/31/2026, the DM or ADM could not provide a policy regarding not preparing enough food for the residents.

Based on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 2 residents (Resident #1) reviewed for pressure injuries. The facility nurse did not provide wound care to Resident #1 on 03/28/2026 as ordered. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain.Findings included: Record review of Resident #1's face sheet dated 3/31/26 revealed a [AGE] year-old female who was admitted into the facility on 2/1/2026 with an initial admission date of 2/22/2023. Resident #1 was diagnosed with type 2 diabetes mellitus with circulatory complications (various cardiovascular issues that can arise due to poorly managed diabetes, significantly increasing the risk of serious health problems), acute combined systolic (congestive) and diastolic (congestive) heart failure (a serious condition where the heart cannot pump enough blood, requiring immediate medical attention), nondisplaced trimalleolar fracture of unspecified lower leg, sequela (a fracture involving the three malleoli of the ankle: the medial malleolus (fibula), lateral malleolus (fibula), and posterior malleolus (tibia), chronic kidney disease, stage 3B (a moderate to severe loss of kidney function, with an estimated glomerular filtration rate (eGFR), edema, unspecified (swelling caused by fluid accumulation in body tissues without a clearly identified underlying cause). Record review of Resident #1's quarterly MDS, dated [DATE] revealed; Resident #1 had a BIMS score of 15, which indicated cognitively intact. M0150. Risk of Pressure Ulcers/Injuries: Is the resident at risk of developing pressure ulcers/injuries - Yes. Record review of Resident #1's Comprehensive Care Plan initiated 02/26/2026, revealed focus impairment to skin integrity of the right anterior leg, right medial leg left second toe; with interventions which include observation of the skin, keep skin clean and dry, hydrate the skin with lotion as needed, and report any skin alterations to the nurse. Record review of Resident #1's Physician Order Summary dated 4/1/2026 revealed an order wound #5 left medial leg venous ulcer to cleanse with wound cleaner, apply betadine moistened gauze to base of the wound, secure with dry dressing, and change daily and PRN; wound #6 right leg venous ulcer to cleanse with wound cleaner, apply betadine moistened gauze to base of the wound, secure with ABD, Kerlix, ace bandage, and change daily and PRN. The orders did not reflect the stages of the wounds. During an interview with Resident #1 on 3/31/2026 at 4:10 pm, Resident #1 stated the nurse provided wound care to her legs daily. During an interview on 3/31/2026 at 2:13 PM with Wound Care Nurse, she stated she provided wound care to Resident #1 Monday through Friday. She stated Resident #1's leg started as a blister and the NP came and gave orders to put betadine (put in a gauze to make it moist and place it on the leg. They were to change the dressing daily and PRN. When the resident takes a shower, the staff can wrap it using gauze, ABD, Kerlix, and an ace bandage. Her last changing was yesterday 3/30/2026 and she stated Resident #1 went to an appointment and she was waiting for her to return to change it. The WCN stated she will change her dressing before she leaves for the day. She stated Resident #1 was noncompliant with the doctors' orders. The WCN stated if it was not changed properly, it could get infected but as of now it was healing and there were no oozing or blisters on the wound. Surveyor reviewed Resident #1 electronic health record and revealed there was no care provided on 3/28/2026. Record review did not reveal what stage the wound was. Observation on 3/31/2026 at 3:45 PM, the wound care nurse was observed providing wound care to Resident #1 legs per the physicians' orders. During an interview on 4/1/2026 at 1:53 PM with the ADM, she stated her expectation for her nurses was to follow the MD or NP orders they have put in place for the staff to care for the residents. They were to also follow what the policy stated. During an interview on 4/1/2026 at 2:25 PM with the DON, she stated it was the responsibility of the nurse to provide wound care to the residents when the wound care nurse was not on duty. She stated if the wound care was not performed, it could worsen, more drainage can occur, pain and discomfort. She did not know why wound care was not performed on the resident. The last wound care was done 3/30/2026. The wound care was not done on 3/28/2026. The one change did not worsen the wound. Record review of facility policy titled Wound Care updated July 2019, revealed the purpose of this procedure is to provide guidelines for the care of wounds to promote healing,

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 4 medication carts, and 1of 2 medication rooms reviewed for medication storage. The facility failed to ensure the medication cart located at nursing station 2 did not contain loose pills and a cup with a pill. The facility failed to ensure an expired cartridge of Humalog, best by 12/25/2024, was removed from the med room [ROOM NUMBER] refrigerator. These failures could place residents at risk for not receiving prescribed medications as ordered and adverse effects of medications due to incorrect labeling.The findings included:On 03/05/26 at 1:02 PM an observation of the medication rooms refrigerator revealed an expired Humalog 100 units/ML cartridge. Dated 12/26/24 for a Resident #1.Record review of Resident #1's face sheet dated 3/6/2026 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmission 6/17/2025 with diagnoses of major depressive disorder, recurrent, mild (someone who experiences distinct, repeated episodes of depression, but with fewer and less severe symptoms than moderate or severe cases, significantly impacting life but without full incapacitation, and with no history of manic or hypomanic episodes), mixed hyperlipidemia (high levels of both cholesterol (especially LDL) and triglycerides in your blood), polyneuropathy, unspecified (damage affecting multiple peripheral nerves (outside the brain and spinal cord) where the specific underlying cause isn't identified or documented), gout, unspecified (the specific type or location isn't documented, but it's a painful inflammatory arthritis from uric acid crystal buildup in joints, causing sudden swelling, redness, and intense pain), disorder or muscle, unspecified (a medical classification for a muscle condition when the specific type isn't known, but it generally involves symptoms like weakness, pain, cramps, or stiffness, affecting the muscles' ability to function properly due to underlying issues with muscle fibers, nerves, or their connection). Review of Resident #1's Quarterly MDS, dated [DATE], reflected the residents had a BIMS score of 14, which indicated she cognitively intact. Resident #1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, lower body dressing, transfers, bed mobility, and toileting hygiene. She was dependent on staff for showers.Review of Resident #1's Comprehensive Care Plan, with revision date of 12/29/2025 reflected Resident # 1 required one staff assistance with bathing, dressing, grooming and hygiene.Observation and interview on 12/29/2025 at 10:45 AM, revealed Resident #1 was in her room lying in bed. Resident #1 stated she received her medication and has not missed a dose. She mentioned she is now taking Ozempic which she is glad because it is also assisting in her losing weight oppose to the other diabetic medication, they had her on. She did not remember the name of the medication.On 03/05/26 at 1:40 PM an observation and interview of the medication cart on pod 2 revealed two loose pills at the bottom drawer of the medication cart along with a cup that contained a single unknown pill. The DON stated she did not know what the pill was and why it was left there but proceeded to discard the medications.During an interview on 3/6/2026 at 1:35 PM, ADON A stated ADON A on pod 2 was responsible for making sure expired medications were discarded. He stated there was a discard box located in both medication rooms. If a resident was discharged or the medications were expired, they were discarded in the box. The narcotics were given to the DON, and she has a lock box in her office, and they place them in there. The pharmacy consultant comes once a month, and they destroy the narcotics. ADON A stated if a resident was given an expired medication they could have no reaction, or it would do what it was designed to do. He stated it can have an adverse rection that can cause an allergic reaction or lead to anaphylactic shock, which they will use an EpiPen to reverse the action. ADON A stated his expectations from his nurses and medication aides was to ensure medications were discarded when expired. They were supposed to discard it in the box with the red bag in the medication room. When the resident discharge or expire, they were responsible for discarding the medication also. ADON A stated he does not know why the medication was in the cart in a cup with no name or the loose pills were in the cart. He stated he was not covering that area, so he was unsure. He stated if the medication was not given, it should come up in the electronic health records as not had been given and they can become sick.During an interview on 3/6/2026 at 1:55 PM, the DON stated it was the responsibility of the nurses and medication aides to make sure expired medications were thrown away. She stated the medication aides were supposed to audit their medication carts to ensure the medicines were up to date, the OTC were up to date, and nurses do a count behind them. The nursing staff and the pharmacy consultant did an audit together. The DON stated the blister packs, discharged residents and expired medication go in there were placed in the red destruction box in the medication room. The DON said the Narcotics go into the DON office to be destroyed. The pharmacy consultant comes, and they do destruction together. She stated that if the expired medication was given to a resident, it could have an adverse reaction such as, they could get sick. Also, if it was expired it was not treating what needs to be treated. The DON stated her expectations from her nurses and medication aides was to audit their carts to ensure medication was discarded when expired. She stated they do share their carts but when the cart was in their possession make sure it was cluttered free, and the expired medication was taken out. The DON stated the Humalog medication should have been discarded because the residents do not use Humalog 100 ML medication anymore. The resident was currently taking Ozempic. The DON stated staff should not keep medication in the cart in a cup with no label on it or have loose pills in the cart. She stated the only reason she can think of was the staff went to give the medication; they did not see the residents and were going to go back and try to give it later. The DON stated if the medication was not given, it would be based on what the medication was used for. For example, if it was blood pressure medication, their BP can be elevated. Best practice was for the residents to receive their medication.During an interview on 3/6/2026 at 2:30 PM, Med Aide A stated it was the responsibility of the med aid and the nurses to throw away the expired medication. He stated the expired OTC medication and any medication he passed out was to be discarded in the bin in the medication room. Med Aide A said if an expired medication was given to a resident, they can have effects from the medication. He stated he did not see the medication in the cup. He stated he does not know whose medication it was. Med Aide A stated everyone should receive their medication. He stated he was not blaming anyone, but he figured the medication was left from the night shift. He stated if he saw loose medication or the medication in the cup, he would have asked the night nurse immediately and would have been advised he should destroy it because you do not know what the medication was or who it was for. He stated when he started his shift, no one had an alert they hadn't received their medication. Med Aide A stated what could happen if the resident does not receive their medication would be based on the medication and the adverse reaction they could have.Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed:Medication Labeling and StorageThe facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have keys.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instruction regarding returning or destroying these items.Medication Labeling5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifics a shorter or longer date for the open vial.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 4 medication carts, and 1of 2 medication rooms reviewed for medication storage. The facility failed to ensure the medication cart located at nursing station 2 did not contain a cup with a pill. The facility failed to ensure an expired cartridge of Humalog, best by 12/25/2024, was removed from the med room [ROOM NUMBER] refrigerator. These failures could place residents at risk for not receiving prescribed medications as ordered and adverse effects of medications due to incorrect labeling.The findings included:On 03/05/26 at 1:02 PM an observation of the medication rooms refrigerator revealed an expired Humalog 100 units/ML cartridge. Dated 12/26/24 for a Resident #1.Record review of Resident #1's face sheet dated 3/6/2026 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmission 6/17/2025 with diagnoses of major depressive disorder, recurrent, mild (someone who experiences distinct, repeated episodes of depression, but with fewer and less severe symptoms than moderate or severe cases, significantly impacting life but without full incapacitation, and with no history of manic or hypomanic episodes), mixed hyperlipidemia (high levels of both cholesterol (especially LDL) and triglycerides in your blood), polyneuropathy, unspecified (damage affecting multiple peripheral nerves (outside the brain and spinal cord) where the specific underlying cause isn't identified or documented), gout, unspecified (the specific type or location isn't documented, but it's a painful inflammatory arthritis from uric acid crystal buildup in joints, causing sudden swelling, redness, and intense pain), disorder or muscle, unspecified (a medical classification for a muscle condition when the specific type isn't known, but it generally involves symptoms like weakness, pain, cramps, or stiffness, affecting the muscles' ability to function properly due to underlying issues with muscle fibers, nerves, or their connection). Review of Resident #1's Quarterly MDS, dated [DATE], reflected the residents had a BIMS score of 14, which indicated she cognitively intact. Resident #1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, lower body dressing, transfers, bed mobility, and toileting hygiene. She was dependent on staff for showers.Review of Resident #1's Comprehensive Care Plan, with revision date of 12/29/2025 reflected Resident # 1 required one staff assistance with bathing, dressing, grooming and hygiene.Observation and interview on 12/29/2025 at 10:45 AM, revealed Resident #1 was in her room lying in bed. Resident #1 stated she received her medication and has not missed a dose. She mentioned she is now taking Ozempic which she is glad because it is also assisting in her losing weight oppose to the other diabetic medication, they had her on. She did not remember the name of the medication.On 03/05/26 at 1:40 PM an observation and interview of the medication cart on pod 2 revealed two loose pills at the bottom drawer of the medication cart along with a cup that contained a single unknown pill. The DON stated she did not know what the pill was and why it was left there but proceeded to discard the medications.During an interview on 3/6/2026 at 1:35 PM, ADON A stated ADON A on pod 2 was responsible for making sure expired medications were discarded. He stated there was a discard box located in both medication rooms. If a resident was discharged or the medications were expired, they were discarded in the box. The narcotics were given to the DON, and she has a lock box in her office, and they place them in there. The pharmacy consultant comes once a month, and they destroy the narcotics. ADON A stated if a resident was given an expired medication they could have no reaction, or it would do what it was designed to do. He stated it can have an adverse rection that can cause an allergic reaction or lead to anaphylactic shock, which they will use an EpiPen to reverse the action. ADON A stated his expectations from his nurses and medication aides was to ensure medications were discarded when expired. They were supposed to discard it in the box with the red bag in the medication room. When the resident discharge or expire, they were responsible for discarding the medication also. ADON A stated he does not know why the medication was in the cart in a cup with no name or the loose pills were in the cart. He stated he was not covering that area, so he was unsure. He stated if the medication was not given, it should come up in the electronic health records as not had been given and they can become sick.During an interview on 3/6/2026 at 1:55 PM, the DON stated it was the responsibility of the nurses and medication aides to make sure expired medications were thrown away. She stated the medication aides were supposed to audit their medication carts to ensure the medicines were up to date, the OTC were up to date, and nurses do a count behind them. The nursing staff and the pharmacy consultant did an audit together. The DON stated the blister packs, discharged residents and expired medication go in there were placed in the red destruction box in the medication room. The DON said the Narcotics go into the DON office to be destroyed. The pharmacy consultant comes, and they do destruction together. She stated that if the expired medication was given to a resident, it could have an adverse reaction such as, they could get sick. Also, if it was expired it was not treating what needs to be treated. The DON stated her expectations from her nurses and medication aides was to audit their carts to ensure medication was discarded when expired. She stated they do share their carts but when the cart was in their possession make sure it was cluttered free, and the expired medication was taken out. The DON stated the Humalog medication should have been discarded because the residents do not use Humalog 100 ML medication anymore. The resident was currently taking Ozempic. The DON stated staff should not keep medication in the cart in a cup with no label on it or have loose pills in the cart. She stated the only reason she can think of was the staff went to give the medication; they did not see the residents and were going to go back and try to give it later. The DON stated if the medication was not given, it would be based on what the medication was used for. For example, if it was blood pressure medication, their BP can be elevated. Best practice was for the residents to receive their medication.During an interview on 3/6/2026 at 2:30 PM, Med Aide A stated it was the responsibility of the med aid and the nurses to throw away the expired medication. He stated the expired OTC medication and any medication he passed out was to be discarded in the bin in the medication room. Med Aide A said if an expired medication was given to a resident, they can have effects from the medication. He stated he did not see the medication in the cup. He stated he does not know whose medication it was. Med Aide A stated everyone should receive their medication. He stated he was not blaming anyone, but he figured the medication was left from the night shift. He stated if he saw loose medication or the medication in the cup, he would have asked the night nurse immediately and would have been advised he should destroy it because you do not know what the medication was or who it was for. He stated when he started his shift, no one had an alert they hadn't received their medication. Med Aide A stated what could happen if the resident does not receive their medication would be based on the medication and the adverse reaction they could have.Record review of the facility-provided policy titled, Medication Labeling and Storage; revised February 2023 revealed:Medication Labeling and StorageThe facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have keys.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.3. If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instruction regarding returning or destroying these items.Medication Labeling5. Multi-dose vials that have been opened or accessed (e.g., needle punctured) are dated and discarded within 28 days unless the manufacturer specifics a shorter or longer date for the open vial.

Based on observation, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse and neglect are reported immediately, but not later than 24 hours if the events that cause the allegation involve abuse and do not result in serious bodily injury for 1 of 3 residents (Resident #1) reviewed for abuse and neglect.The facility failed to ensure that CNA A reported allegation of abuse immediately, but no later than 24 hours to the ADM when Resident #1 reported that her roommate slapped her on her thigh to CNA A.This failure could result in continued abuse or neglect of residents, injury, and/or psychosocial harm.Findings included:Record review of Resident #1's face sheet dated 02/26/26 reflected a [AGE] year-old female admitted on [DATE] with diagnoses of type 2 diabetes, mild protein-calorie malnutrition, hypertension, cerebral infarction (stroke) , monoplegia of upper limb (paralysis of arm), muscle weakness, unsteadiness on feet and lack of coordination.Record review of Resident #1's care plan dated 02/25/26 reflected Resident #1 experiences loneliness and /or isolation and the relevant intervention was, encouraging resident to express feelings of loneliness and isolation.Record Review of Resident #1's quarterly MDS dated [DATE] reflected BIMS score of 15 which indicated there was no cognitive impairment. Further review reflected Resident #1 had no physical, verbal or other behavioral symptoms directed towards others. Record review of the FRI dated 02/17/26 indicated that the SW reported to the ADM that, during a session on the same date, the LPC conveyed that Resident #1 had disclosed that her roommate had slapped her in the face approximately two weeks prior. However, when the ADM subsequently interviewed Resident #1, she stated that her roommate had hit her on the thigh several weeks earlier.Record review of the Provider Investigation Report dated 02/24/26 revealed that, during the facility investigation, it was documented that Resident #1 had reported to CNA A on 02/07/26 that she did not like her roommate because she had hit her in the past and CNA A had not reported the allegation to the AC at the facility.During an interview on 02/26/26 at 12:30 PM, the SW stated that on 02/17/26, the LPC informed him that Resident #1 had reported her roommate had hit her in the face. The SW also noted that the LPC mentioned Resident #1 had reported to her that she had informed CNA A and other staff members about the incident. The SW stated that he immediately reported the allegation to the ADM, who served as the AC at the facility.During an observation and interview on 02/26/26 at 12:30 PM, Resident #1 was observed lying in bed. She reported that she was satisfied with her current room and her new roommate. Resident #1 indicated that her previous roommate had been unkind and had taken her belongings, primarily food items brought in by her FM, without her permission. She stated that approximately a few weeks prior, when she confronted her former roommate about her behavior, the roommate responded by slapping her on the right thigh. Resident #1 reported that she disclosed the incident within a few days to multiple CNAs who worked with her; however, she did not recall their names. Resident #1 stated that she immediately reported the incident to the FM and further recalled informing CNA A about the incident several days afterward. She noted that, although no further incidents occurred, she did not feel safe remaining in the same room with her previous roommate. Resident #1 expressed that she felt more comfortable after moving to her current room.During a telephone interview on 02/26/26 at 1:34 PM, the FM reported that Resident #1 disclosed the incident to her the day after it occurred, during a visit. The FM stated she had reported the incident to a staff member working on the floor on the same day but was unable to recall the staff member's name or role within the facility. She further indicated that the ADM recently discussed the incident with her and instructed her to report any complaints, preferably directly to the administrator rather than to other staff members on the floor. The FM expressed that this approach was new to her, as she previously believed she could report concerns to any staff member. She noted that no injuries or visible harm resulted from the incident and expressed satisfaction that the facility took steps to relocate Resident #1 away from the alleged perpetrator. She added, however, it would have been better if the roommate was removed from the room rather than Resident #1 moving to a different room. The FM stated she was generally satisfied with the care and services provided to Resident #1 at the facility thus far.During an interview on 02/26/26 at 11:10 AM CNA A stated that approximately few weeks prior, while changing Resident #1, the resident indicated that her roommate had hit her at some point in the past. CNA A stated that she did not inquire about the specific timing of the incident, nor did she ask the resident for more details. She said that she initially took the report lightly, as Resident #1 was discussing other topics and laughed it off. She stated that Resident #1 reported to her that she had previously reported the incident to other staff members at the time that had occurred, though she did not disclose their names. CNA A explained she had chosen to not to report the incident to AC because of Resident #1's statement that she reported about the incident to other CNAs, also it was in the past, and the resident did not appear to be upset about it at the time. CNA A recognized the ADM as the AC and acknowledged that she later received a one-on-one in-service from the AC. She stated she understood that her failure to report the allegation was a mistake. CNA A stated she learned that any allegation of abuse, regardless of when it occurred, should be reported to the AC.During an interview on 02/26/26 at 2:30 PM, the DON reported that she learned of the allegation through the SW. The DON stated, the LPC had informed the SW that, on 02/17/26, during a session with Resident #1, the resident disclosed that her roommate had assaulted her approximately two weeks earlier by smacking her in the face. However, upon further inquiry by the ADM, Resident #1 clarified that her roommate had hit her on the thigh and not on the face, several weeks prior. The DON said, since the roommate did not want to move out of the room, they asked if she wanted to move rooms, Resident #1 expressed a desire to do so and was promptly relocated. The DON stated Resident #1 reported feeling safe at the facility and was satisfied with the room change. The DON said when the roommate was interviewed, she denied ever hitting Resident #1, stating that although they had disagreements, she had never physically assaulted her. She said, both residents were under psychiatric care, with no prior documentation of such incidents in their sessions. The DON stated, the psychiatric team continued to monitor and followed up with both residents and during a follow-up psychiatric assessment on 02/19/26, Resident #1 was specifically asked about the alleged assault. The DON said, Resident #1 did not confirm any physical aggression and instead focused on property disputes and reported feeling happier and safer in her new room. The DON said on 02/17/26 the FM of Resident #1 was contacted and informed of the incident and room change. The FM acknowledged that Resident #1 had previously mentioned being hit in the face but explained she did not report it because she was not hurt. The FM was advised of the importance of reporting such incidents promptly and verbally committed to doing so in the future, even for minor concerns. The DON stated, staff questionnaires completed after the incident revealed that CNA A had briefly mentioned that Resident #1 had reported the incident weeks earlier to her, noting it as a distant past event. The DON stated that CNA A said she did not report this incident to anyone in the facility as the incident had happened in the past. A one-on-one in-service was conducted with CNA A emphasizing the necessity of reporting all potential abuse, regardless of timing, to ensure proper documentation and investigation per facility policy. The DON stated she performed a comprehensive skin assessment on both residents, confirming no abnormalities from baseline. The DON said she conducted resident safety surveys to all residents in the 800 hall, including Resident #1, which showed no concerning trends. Additionally, staff training sessions on abuse, neglect, reporting procedures, and de-escalation techniques for residents with behavioral issues were implemented to improve staff awareness and response. When the investigator clarified that the FM was instructed by the ADM to report incidents directly to the administrator rather than to floor staff, the DON stated that this was inappropriate. She emphasized that residents and their families had the right to report concerns to any staff member, and it was the staff member's responsibility to escalate and report such complaints to the appropriate authority.An interview with ADM on 02/26/26 at 2:30pm was unsuccessful as she was on leave and was not accessible via mobile phone.Record review of in-service dated 02/17/26 reflected in-service was conducted with all staff over topic of Reporting abuse and neglect when anyone reports abuse or neglect regardless of time frame. All incidents should be reported to abuse coordinator. De-escalation techniques for residents with behaviors. It was also revealed that CNA A received a separate 1:1 in-service on the same subject on 02/17/26, from the AC.Record review of facility policy Abuse, Neglect, Exploitation and Misappropriation prevention program revised in April 2021 reflected: Reporting Allegations to the Administrator and Authorities:If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law and HHSC reporting guidelines. 3.Immediately is defined as:n. within two hours of an allegation involving abuse or result in serious bodily injury; orb. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.

Based on interviews, observations, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that meet professional standards of quality care for 1 (Resident #2) of 4 residents reviewed for baseline care plans. The facility failed to update Resident #2 care plan on 12/28/2025 after they received orders from the nurse practitioner in regard to his rash.This failure could place residents at risk of getting insufficient care and having personal needs not met and could result in diminished physical and psychosocial well-being.Findings included:Review of Resident #2's face sheet dated 12/29/2025 reflected that he was a [AGE] year-old male admitted [DATE] with diagnoses of chronic obstructive pulmonary disease with (acute) exacerbation (a sudden, significant worsening of a person's COPD symptoms, like increased breathlessness, coughing, and mucus production (more volume, thicker, or changed color), usually triggered by infections or pollutants, requiring extra treatment and potentially leading to hospitalization, impacting lung function, and reducing quality of life), other secondary hypertension (high blood pressure that's caused by another medical condition), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a specific diagnostic code (like ICD-10 code F03.90) used when someone shows symptoms of dementia (memory loss, thinking problems, impaired daily function) but a precise type (like Alzheimer's or Vascular) isn't identified, the severity isn't clear, and significant behavioral issues like agitation, depression, or anxiety aren't present), type 2 diabetes mellitus with unspecified complication (a chronic condition with high blood sugar due to insulin resistance, and is experiencing secondary health problems (complications) that haven't been precisely identified or coded yet, but are known to stem from the diabetes), difficulty in walking not yet specified (abnormalities of gait or mobility where the exact underlying cause has not yet been identified or classified). Review of Resident #2's 05/15/25 admission MDS reflected his BIMS score was 15, which indicated Resident #2 was cognitively intact.Record review of Resident #2' s orders revealed orders for: Doxycycline Hyclate Oral Tablet 100 MG (Doxycycline Hyclate) Give 100 mg by mouth twice a day for 7 days. Ketoconazole External Cream 2% (Ketoconazole Topical) Apply to left ABD twice a day for 7 days. Fluconazole Oral Tablet 100 MG (Fluconazole) Give 100 mg by mouth twice a day for 14 days. Review of Resident #2's assessments reflected a Care Plan updated on 12/29/25, revealed rash to torso and under the breast, antibiotic therapy Doxycycline 100 mg daily PO Ketoconazole cream topical, and Fluconazole 100 mg daily was not included. Once questions were asked, the Care Plan then reflected focus, goal, and intervention/tasks in regards of the rash. Focus: Risk for Self-Care Deficit: Bathing, Dressing, Feeding. Goal: Resident will be able to perform Self-care needs. Intervention/Task: Encourage resident to participate in planning day-to-day care, evaluate functional abilities, and aid with ADLs as needed.Record review of Resident #2' s Progress Notes dated 12/28/2025 at 7:43 PM revealed, LVN A notified FNP about Resident #2 rash on 12/28/2025. Resident #2 was seen by FNP 12/28/2025 on telehealth virtual visit for a rash that was on the left side of the front of his torso area and under both breast areas. Resident stated it itches during the day and night as well. The nurse ordered to continue topical Nystatin (is an antifungal, antibiotic treatment for fungal infections of the skin) and Ketoconazole (used to treat various fungal skin conditions) cream BID along with oral doxycycline for 7 days and fluconazole PO for 14 days. Resident #1 was educated on hygiene of hands and refused an PO PRN for s/s of pain and reaction.During an interview and observation with Resident #2 on 12/28/2025 at 10:20 AM, revealed he does not have any sores from lying in bed, but he has a sore under his left breast that he had for a couple of days. Resident #2 stated the redness under his breast along with creamy white gooey substance. He stated they had put some cream on it. Resident #2 stated he cannot make it to the bathroom sometimes and he wet his bed and that was why he has the rash under his breast. During the interview and observation, there was no odor from Resident #2, but he appeared to be unkept lying in bed halfway.During an interview with CNA B on 12/28/2025 at 11:40 AM, revealed Resident #2 has a rash and cannot diagnosis it. She stated he had complained he needed it washed, and he was showered. He also revealed the rash hurt, and she reported it to the nurse. CNA B stated he was given a shower and placed the medicated powder the charge nurse gave her.During an interview with LVN A on 12/29/2025 at 11:58 AM, it was revealed that Resident #2 has an order for cream, and it has gotten better. He advised her he had it for a few days. She took a picture of the rash, and the NP gave her 4 different orders along with the Nystatin steroid cream, doxycycline, and another antibiotic by mouth. LVN A stated he will lay in bed and do not go to the restroom. She stated at night they try to get him to use the briefs. He was previously moved from another room due to him urinating on the floor or wherever and had the room smelling like urine. He will not go to the bathroom and will lie in the urine. LVN A stated they provided him with a female urinal because the hole was bigger. She stated she was not sure if he was ashamed of the briefs, but he can go to the restroom by himself. If the Care Plan is not accurate the residents will not be able to get the proper care they need.In an interview with Med Aide A on 12/29/2025 at 1:58 PM, it was revealed that she has been employed here for four years, and Resident #2 has had a rash. She stated they do not know what was causing the rash. He refuses to take a shower, but he is getting better. The nurse gives them cream to apply to him. He sits in urine all day. He does not have a brief. He can go to the bathroom. They will ask him to get change, and he denies needing to be changed. He was embarrassed to wear them. He stated he was a grown man, and he should not have to wear them. She stated if the resident care plans are not correct, it can be something that can cause potential harm they will not get the proper care they need.In an interview with CNA A on 12/29/2025 at 3:00 PM, it was revealed that she noticed the rash on Resident #2 on Saturday and she reported it to the nurse and the orders were put in and she gave the cream to the CNAs. She stated he does not complain about it hurting, he just states its itching. When they change him, they put the cream on him. During the daytime he goes to the bathroom by himself but at nighttime he puts the brief on. She stated if care plans are not updated, the residents will not get the care they are supposed to have.In interview with DON on 12/29/2025 at 3:10 PM, revealed that Resident #2 has had the rash underneath the folds under his breast and it is moist along with redness and they had been using nystatin cream. Over the weekend, they started seeing it more, and it got worse, and the nystatin was not doing anything about it, so they got orders for the antibiotics by mouth. She stated he stays non-compliant with not wearing the brief and she thinks he is embarrassed. DON stated they sent a man to talk to him regarding his private area. They also sent the male nurse to speak to him to use the woman urinal since it is bigger at the mouth part. She stated he stays moist due to his size. DON stated he takes his scheduled showers and now they give it to him daily to help with the odor and his hygiene. They noticed the rash this weekend. The DON stated if the care plan is not updated, the staff cannot take care of the residents properly. The direct care cannot be given. Their care plans give you a window about that resident. Everything catered to each residents' needs. Residents may have aggressive behaviors so you know who can go in the room with them or someone cannot have a roommate with them. Some must be carefully planned because they are not compliant with smoking break, and it can lead to them hurting themselves or burning the building.In an interview with MDS Coordinator on 12/29/2025 at 12:45 PM, revealed that Resident #2 has had a rash. She stated as the MDS Coordinator documents the chronic care plan once the resident gets admitted into the facility, the falls/accidents, antibiotics therapy, skin tears, and pressures ulcers. The MDS Coordinator or ADON depends who catches the changes will speak on in the morning meeting. If the care plan or the MDS is not current or updated nothing will happen because the staff go by the orders and their ADLs to care for the residents. The long-term residents care plans are updated quarterly to match their quarterly assessments.Record review of the facility's Care Plans, Comprehensive Person-Centered, policy revised December 2016, revealed in part A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions changes.

Based on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one of four residents (Resident# 1) reviewed for ADL care.The facility failed to provide Resident #1 showers consistent on her shower days who were physically impaired.This failure could place ADL dependent residents at risk of experiencing embarrassment from odors, infection, and skin breakdown.Findings included:Record review of shower schedule from electronic records revealed the following:Resident #1- was scheduled for Tuesdays, Thursdays, and Saturdays on the 2pm-10pm shift for December 2025. The following dates revealed the resident received showers:12/2/2025 at 17:31 pm12/4/2025 at 23:22 pm12/6/2025 at 22:39 pm12:8/2025 at 4:08 am12/9/2025 at 23:46 am12/11/2025 at 22:43 pm12/13/2025 at 15:20 pm and 22:19 pm12/17/2025 at 00:01 am and 17:59 pm12/18/2025 at 4:07 am12/19/2025 00:41 am12/20/2025 at 00:56 am12/21/2025 at 2:52 am12/24/2025 at 14:52 pm12/26/2025 at 5:59 amRecord review of Resident #1's face sheet dated 12/29/2025 reflected she was a [AGE] year-old female who was admitted to the facility on [DATE] and readmission 6/17/2025 with diagnoses of major depressive disorder, recurrent, mild (someone who experiences distinct, repeated episodes of depression, but with fewer and less severe symptoms than moderate or severe cases, significantly impacting life but without full incapacitation, and with no history of manic or hypomanic episodes), mixed hyperlipidemia (high levels of both cholesterol (especially LDL) and triglycerides in your blood), polyneuropathy, unspecified (damage affecting multiple peripheral nerves (outside the brain and spinal cord) where the specific underlying cause isn't identified or documented), gout, unspecified (the specific type or location isn't documented, but it's a painful inflammatory arthritis from uric acid crystal buildup in joints, causing sudden swelling, redness, and intense pain), disorder or muscle, unspecified (a medical classification for a muscle condition when the specific type isn't known, but it generally involves symptoms like weakness, pain, cramps, or stiffness, affecting the muscles' ability to function properly due to underlying issues with muscle fibers, nerves, or their connection). Review of Resident #1's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 14, which indicated she cognitively intact. Resident #1 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, lower body dressing, transfers, bed mobility, and toileting hygiene. She was dependent on staff for showers.Review of Resident #1's Comprehensive Care Plan, with revision date of 12/29/2025 reflected Resident # 1 required one staff assistance with bathing, dressing, grooming and hygiene.Observation and interview on 12/29/2025 at 10:45 AM, revealed Resident #1 was in her room lying in bed. There were no foul odors in the room, Resident #1 looked clean, she stated no one had been in her room yet to take her clothing out for her to put on for the day. Resident #1 stated it depends on who was giving the showers that day and she gets them at night. She stated she received her shower on 12/27/2025 and the previous Saturday on 12/20/2025. Record review revealed the resident received a shower on 12/21/2025, 12/24/2025, and 12/26/2025. Resident #1 stated she was told the water was cold and they had to fix it, and she could not give her a shower. She stated she could give her a bed bath, but Resident #1 refused wanting to take a bed bath with cold water. Resident #1 stated if she had any concerns she will tell the SW, nurse on duty, or the DON regarding the CNA and she will escalate it up by contacting the Ombudsman. Resident #1 could not provide which staff member advised her the water was cold so that staff member was not interviewed.In an interview with DON on 12/29/2025 at 3:10 PM, revealed that certain residents do not like to get out of bed until after breakfast and before lunch. DON stated Resident #1 does not refuse showers and makes her own decisions. She stated she is very pleasant and outspoken. She stated sometimes she wants a bed bath. DON stated if the residents refused their showers, the nurse would find out why, and she would contact the family and write a progress note. They will try to get their shower done the next day. They will ask them. If they do not get it, they will end up on their rotation day. She stated if they do not receive their showers, they can smell, skin breakdown, all kind of health issues, UTI, yeast infections, even with the men. They will also feel bad about themselves, and it can cause them to have mental health. In an interview with CNA A on 12/29/2025 at 3:00 PM, revealed that if residents do not receive their showers, they will have skin issues and that is not good for them. Living in an environment that will not smell good and the breakdown of the residents with sensitive skin. CNA A stated Resident #1 receive showers and she is vocal.In an interview with Med Aide A on 12/29/2025 at 1:58 PM, revealed that Resident #1 refused showers and request a bed bath instead. She will take a shower once a week and the rest of the week she will request a bed bath. She stated she was outspoken, and she will not allow you to leave her dirty. She stated if the residents do not take a shower, it can lead to skin issues (breakdown of the skin) and dignity issues.In an interview with LVN A on 12/29/2025 at 11:58 AM, revealed that Resident #1 was one of the five residents that like to get up late. She stated she Resident #1 gets her showers and she did not hear of any complaints about her not getting her shower. She is very outspoken and energetic and always out in the community. She stated if the residents do not get their showers, it can cause skin breakdown, and they can start feeling some kind of way.In an interview with ADM on 12/29/2025 at 3:55 PM, it revealed that if the residents do not receive their showers, they can have skin breakdown and hygiene concerns from their neighbors if they are in the common area or their roommates. But the most concern is the skin breakdown. She stated Resident # 1 is vocal in everything she does and has not complained or stated she was not receiving her showers.Review of the Facility's Policy on Activities of Daily Living, dated 03/2018, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to conduct ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene.

Based on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for Resident #2 reviewed for misappropriation. The facility failed to ensure Resident #2 was protected from the AC accessing her bank account, leading to 4 unauthorized transactions totaling $10,250 from Resident #2's account between 10-18-2025 and 10-29-2025. This failure could place residents at risk of decreased quality of life, property misappropriation, and financial hardship.Findings included: Record review of Resident #2's admission record , dated 12-03-2025, indicated an [AGE] year-old female admitted to the facility on [DATE] with primary diagnoses of cerebral infarction, unspecified (blood flow to the brain disrupted due to issues with the arteries that supply it), and secondary diagnosis of Alzheimer's disease Resident #2 was her own responsible party, Record review of Resident #2's Quarterly MDS Assessment, dated 11-05-2025, revealed Resident #2 had a BIMS score of 12 , indicating impairment, 8 - 12 = moderate cognitive. Record review of Resident #2's Care Plan, dated 05-08-2025, indicated Resident #2 was impaired mobility, and used psychotropic medications r/t Alzheimer's disease process. Record review of Resident #2's bank statement revealed the following: 10/10/2025 for $1,300 cash withdrawal10/18/2025 for $3,600 for a charge to loan company10/28/2025 for $2,000 cash withdrawal10/29/2025 $3,350 cash withdrawal Record review of the facility's residents' safe survey, in-service training on misappropriation of funds, and staff questionnaire completed on 11-20-2025. In an interview with Resident #2 on 12-03-2025 at 1:15 p.m., Resident #2 stated AC talked her into putting AC on her bank account. Resident #2 stated the AC told her she could help her with her finances because she had taken Resident #2 to the bank. Resident #2 stated she did not know the AC would take money without her knowing or she would not have put AC on her bank account. Resident #2 stated she did not know the AC was stealing money from her and did not know the total amount taken. Resident #2 stated only $3,500 was returned to her. Resident #2 could not remember the exact amount that AC had taken. In an interview on 12-03-2025 at 2:00 pm the CMA stated on 11-19-2025 while she passed medications, she heard the AC telling Resident #2 in Spanish not to tell anybody about the money. The CMA did not know the amount of money. The CMA stated she reported what she heard to the ADM the same on 11-19-2025. CMA stated she was in-serviced on abuse, neglect, and exploitation, and the last time was a couple of weeks ago. The CMA stated if she saw abuse, neglect or exploitation, she reported it to the ADM.In an interview on 12-03-2025 at 3:10 pm, the ADM stated Resident #2 told her on 11-19-2025 Resident #2 put AC on her bank account and then taken money from the account without Resident #2 permission The money that was taken out was supposed to be for Resident #2s friend, but AC did not bring the money to Resident #2. The ADM talked to AC on 11/19/2025. The ADM stated on 11/20/2025, Resident #2's bank statements, dated 09/26/2025 to 10/25/2025 and 10/26/2025 to10/29/2025, had both the AC's and Resident #2's names on the bank account. The transaction summary for money withdrawn from residents account were as follows: On 10/10/2025 for $1,300 cash withdrawal, 10/18/2025 for $3600 for a charge to a loan company 10/28/2025 for $2,000 cash withdrawal, and 10/29/2025 $3,350 cash withdrawal. On 11/21/2025, a certified letter was mailed to the address on file for AC, requesting the money be returned to Resident #2 , but there was no response from AC In-services on misappropriation were started for all staff, residents were offered psychiatric services, safe survey questions on residents' employee transported places conducted and no trends of abuse or neglect were found. Employee questionnaires were also conducted, and no trends of abuse or neglect found. ADM said Resident #2 took care of her own finances, so they did not know AC had taken the money. ADM stated that when they found out AC took money from Resident #2 they started their investigation and did a self report. Record review of AC employee file showed that AC was terminated from her employment at the facility on 11-20-2025. Record review of the facilities investigation report for their investigation of the misappropriation of funds. Record review of Resident #2 financial records that showed the withdraws of the funds from residents account, Record review of facility policy, titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2021, revealed, 1. Protect residents from abuse, neglect, exploitation, or misappropriation of property by anyone including, but not necessarily limited to: facility staff2. Develop and implement policies and protocols to prevent and identify: Theft, exploitation or misappropriation of resident property.4. Conduct employee background checks and not knowingly employ or otherwise engage any individual who has: Been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; Had a finding entered into the state nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property; or A disciplinary action in effect against his or her professional license by a state licensure body as a result of a finding of abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property.

Based on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 2 (Residents #63 and #65) of 2 residents reviewed for smoking. The facility failed on 9/2/2025 to ensure that Residents #63 and #65 did not smoke without supervision and did not keep their personal cigarettes and lighters in their rooms, as per facility policy. This failure could place residents at risk of an unsafe smoking environment and injury. Findings include: Observation on 9/02/2025 at 11:19 AM revealed Resident #63 was observed in the designated smoking area for the facility, with a cigarette in her hand, smoking. There was no staff supervision in the smoking area at the time Resident #63 was smoking. There were no unsafe behaviors, and she did not have injuries from smoking. There is no evidence that she has been injured while smoking unsupervised. The resident did not say that they had been burned or injured while smoking cigarettes unsupervised. In an interview on 9/02/2025 at 11:25 AM, Resident #63, who was outside in the smoking area of the facility, said that she kept her cigarette lighter and cigarettes in her purse in her room. Resident #63 said that she was an adult and could smoke whenever she wanted. Resident #63 stated that sometimes staff came out and supervised smoking, and sometimes they did not. The resident said she was not the only one who came outside and smoked cigarettes without supervision. A review of Resident #63's medical diagnosis in PCC on 9-2-2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with the following diagnoses: acute respiratory failure (lungs can no longer effectively transfer oxygen to the blood or remove carbon dioxide from it.), unspecified, muscle wasting and atrophy (wasting, or thinning, of muscle tissue), muscle weakness, and lack of coordination. A review of Resident #63's MDS dated [DATE] reflected that Resident #63 had a BIMS score of 15, indicating she was cognitively intact. Review of Resident #63's care plan dated 6/18/2025 reflected that Resident #63 needed staff supervision/adaptations when using tobacco products. A review of Resident #65's medical diagnosis in PCC, reflected a [AGE] year-old female who was admitted to the facility on [DATE], with the following diagnoses: essential hypertension (high blood pressure), weakness (lack of physical or muscle strength), anxiety disorder (intense, excessive, and persistent feelings of fear and worry), lack of coordination (muscle control problem), and muscle weakness (muscles are not as strong as they should be). A review of Resident #65's MDS dated [DATE] reflected that Resident #65 had a BIMS score of 15, indicating she was cognitively intact. Review of Resident #65's care plan dated 6/18/2025 reflected that Resident #65 required staff supervision/adaptations when using tobacco products. In an interview on 9/02/2025, Resident #65 was in her room, and she said there were smoking times at the facility. Resident #65 stated that she kept her cigarettes and lighter with her in her room. Resident #65 said she smoked cigarettes when she wanted. Resident #65 said that the staff were not always outside when residents smoked. There was no observation of her smoking without supervision. In[ an interview on 9/2/2025 at 2:37 PM, the HRD stated that residents were not to go outside and smoke alone. The HRD stated that staff should always be with residents when they were smoking. The HDR stated that residents were not supposed to have cigarettes and lighters in their rooms. The HRD stated that residents' cigarettes and lighters were kept at the nurses' station that was closest to them. The HRD stated that if it was not the designated smoking time, residents could smoke cigarettes if a staff member went outside with them. The HRD stated that residents could get burned, hurt each other, or have a medical issue if there was no supervision while they were smoking outside. HRD was not aware if she had ever burned themselves, started a fire, or smoked around oxygen. In an interview on 9/2/2025 at 2:45 PM, the CN stated that the smoking times at the facility were 9:00 AM, 11:00 AM, 3:00 PM, 7:00 PM, and 9:00 PM. The CN stated that residents were allowed to go outside during designated smoking times. The CN stated that residents should not smoke unsupervised. The CN stated that cigarettes and lighters were to be kept in the Med room, and not in the residents' rooms. The CN Stated that if a resident was smoking unsupervised, it could be a fire hazard and a safety hazard. The CN stated that residents could get burned from the cigarettes or cause a fire. CN was not aware if she had ever burned themselves, started a fire, or smoked around oxygen. In an interview on 9/2/2025 at 2:59 PM with ADM, she stated that residents are supposed to be supervised when smoking. ADM stated that their previous smoking policy was that residents could smoke without any supervision if they were capable. ADM stated that now residents are required to have staff present when they are smoking, and they are only to smoke during smoking times. ADM said that she did not know that residents were smoking unsupervised. ADM said that she is not aware that any residents have been burned, had something catch on fire, or been injured. ADM said that if a resident is smoking unsupervised, they could get burned or injured or catch something on fire. ADM said that there will be an in-service with staff, and residents will be reminded. Review of the facility's Smoking Policy dated 10/2022 reflected: Any resident with restricted smoking or smokeless tobacco privileges requiring monitoring shall have thedirect supervision of a staff member, family member, visitor or volunteer worker at all times while smokingor using smokeless tobacco. Residents may not have or keep any smoking articles, including cigarettes, tobacco, etc., except when theyare under direct supervision.

Based on observations, interviews, and record review, the facility failed to accommodate the needs and preferences for one of seven residents (Residents #1) reviewed for accommodation of needs, in that:The facility failed to ensure that Resident #1 had his call light in reach on 8/8/2025. This deficient practice could place residents at risk of injury, for not receiving timely care and nursing interventions.Findings included: Review of Resident #1's Face sheet dated 8/8/2025 reflected a [AGE] year-old male admitted on [DATE] with diagnoses that included: Hemiplegia (paralysis of one side of the body, Chronic Kidney Disease, Heart Failure, Obstructive Uropathy (disrupted urine flow) and, Atrial Fibrillation (irregular heart rhythm). Review of admission MDS dated [DATE] for Resident #1 reflected a BIMs of 14 suggesting no cognitive impairment. Review of Resident #1's Care plan dated 8/8/2025 for Resident #1 reflected the focus I am at risk for falls [related to] impaired mobility, with the Intervention: Evaluate, interview and document my physical condition and cognitive status.Observe environment to identify any potential factors that could contribute to a fall, such as lighting, uneven/slippery/cluttered floor surfaces, improper footwear, failure to use assistive devices, etc. Remove any potential causes or hazards, if possible. Educate me of potential fall hazards. An observation of Resident #1's room on 8/8/2025 at 11:18 am revealed resident was lying in bed on his back, face up and was awake and alert. Further Observations revealed resident's call light was laying on the floor behind the head of his bed and out of his reach. During an interview on 8/8/2025 at 11:15 am, Resident #1 stated he did not know his call light was laying on the floor behind the bed as he could not see it. He stated he was partially paralyzed and needed his call light to call staff for assistance as he needed assistance for his activities of daily living. Resident #1 stated he would not be able to call for help if he needed to because he could not reach his call light. Resident #1 stated he did not know how the call light got on the floor behind his bed, but he did not put it there. During an interview on 8/8/2025 at 11:21 am, RN A noted that Resident #1's call light was on the floor the call light was not quite where he [Resident #1] could reach it without it being a risk to him. He further stated if Resident #1 attempted to reach for the call light on the floor, he could fall out of bed and get injured. During an interview on 8/8/2025 at 2:42 pm, the Regional Nurse stated the call lights should always be within reach so that residents can get staff when they really needed them. She stated her concern with the call light not being in reach would be that residents would not be able to get the assistance they needed. During an interview on 8/8/2025 at 2:46 PM, LVN C stated she had seen Resident #1 earlier that morning when making her hospice rounds. She stated, at that time, the call light was in reach. She stated she would have safety concerns for Resident #1's call light not being in reach, because he would not be able to get help if he needed it, and could possibly fall out of bed while trying to reach his call light. During an interview on 8/11/2025 at 3:30 pm, the ADM stated any staff that went in a resident's room could have made sure the call light was in reach. She stated her concern with a call light being on the floor would have been that the patient would not be able to make their needs known which could lead to a failure of care. Review of the facility's policy Call System, Residents updated January 2025, reflected the following: Residents are provided with a means to call staff for assistance through a communication system that directly callsa staff member or a centralized work station.Policy Interpretation and Implementation1. Each resident is provided with a means to call staff directly for assistance from his/her bed, fromtoileting/bathing facilities and from the floor. Review of the facility's policy Resident Rights, revised February 2021, reflected the following: Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 10 residents (Resident #1) reviewed for accidents and supervision.The facility failed to ensure Resident #1 did not exit the facility without staff's knowledge and ambulate approximately 100 yards down their driveway to a busy street with a speed limit of 65 MPH on 05/25/25. The facility failed to ensure staff were knowledgeable on how to properly secure the doors using the door security box located at 2 of 2 nurses' stations (both the skilled nursing and long-term care sides of the facility). Staff were identified by ADON B pressing the door release button with a key emblem instead of the round door secure button resulting in the doors not being secured. An Immediate Jeopardy (IJ) was identified on 06/25/25. The IJ Template was provided to the facility on [DATE] at 05:10 PM. While the IJ was removed on 06/26/25, the facility remained out of compliance at a scope of isolated and a severity with no actual harm with the potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of harm and/or injury due to elopement. Findings included:Review of Resident #1's face sheet dated 06/25/25 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included Parkinson's disease (neurodegenerative disease primarily of the central nervous system, affecting both motor and non-motor systems) with Dyskinesia (uncontrolled, involuntary movements), Alzheimer's disease (a type of dementia that affects memory, thinking, and behavior), mood disorder due to known physiological condition with depressive features, and neurocognitive disorder with Lewy bodies (aka Lewy body dementia, is a type of dementia caused by protein deposits in the brain cells affecting thinking, memory, movement, sleep, and behavior). The face sheet reflected Resident #1 was discharged [DATE] at 2:09 PM after a 13-day length of stay. Review of Resident #1's discharge MDS assessment return not anticipated dated 05/25/25 reflected section A discharge status which was marked as Resident #1 being discharged to a long-term care facility with a discharge date of 05/25/25. Section C cognitive patterns reflected a BIMS score of 04 indicating severe cognitive impairment. Review of Resident #1's baseline care plan dated 05/12/25 reflected safety risks- is the resident an elopement risk? was not marked yes or no. Review of Resident #1's care plan last revised 05/25/25 reflected a focus initiated on 05/25/25 the resident is an elopement risk/wanderer related to disoriented to place. History of attempts to leave facility unattended, impaired safety awareness. Resident wanders aimlessly, significantly intrudes on privacy or activities. The care plan reflected there was no focus or interventions prior to 05/25/25 the date of the elopement. Review of Resident #1's progress notes reflected the following notes related to wandering/exit seeking behavior: - Nursing note dated 05/14/25 resident on follow up day 3/3 of new admit. He seems to be adjusting to being at facility. Does continue to wonder around. Alert to self but pleasantly confused. - Nursing advanced skill evaluation dated 05/15/25 resident wanders at night. - Nursing note dated 05/15/25 resident observed making multiple attempts to exit the facility through the secure doors. When redirected resident expressed confusion stating, I don't know what I am doing here. This nurse provided reorientation and education regarding his current medical condition and reason for admission. Resident has a feeding tube, medications and nutritional feeding were administered via tube as ordered. Despite tube feeding, resident was observed attempting to consume food from other residents' tray and requesting coffee. Staff have been providing frequent redirections and reassurance. Resident was brought to nursing station for closer observation; however, he is unable to remain seated for prolong period and frequently attempts to stand and ambulate unsafely. This nurse has made several multiple interventions to promote safety including verbal redirections. - Nursing note dated 05/15/25 Resident found in room packing his clothes and personal belongings which were laid out on his bed. When asked what he is doing he states that he is going home, and his family member is coming to pick him up. Resident educated and redirected but resident remains insistent on leaving. This nurse attempted to contact family member , resident in his room alert and verbal still expressing desires to go home.- A nursing note dated 05/17/25, Resident up in his wheelchair at this time wheeling around everywhere trying to get into other residents' rooms and trying to eat and drink everyone's food and drinks. Resident has to be reminded that he cannot eat or drink anything at this time as he is strictly to not have anything by mouth and that he has a feeding tube that hives him the foods and fluids he needs. Resident stares at nurse and just wheels off. He is very confused, but it is a pleasant confused. Resident attempting to go towards the doors and staff again has to redirect him that he cannot go out of the building as he can fall and get hurt. Resident again just stared at nurse. He is currently wheeling around the nurses station. - A nursing note dated 05/18/25, Resident is up in his wheelchair at this time rolling around and will not stay in pod 1 as it has been asked of him to do that many of times so staff can keep a better eye on him- An advanced nursing skilled evaluation note dated 05/19/25, Resident is confused. Resident is awake at night. Resident wanders at night. - A nursing progress note dated 05/19/25, Resident is up in his wheelchair at this time rolling around and will not stay in pod 1 as it has been asked of him to do that many of times so staff can keep a better eye on him and he continues to go towards the doors and into other residents rooms. He is very pleasantly confused. - An advanced skilled nursing evaluation note dated 05/20/25, safety concerns- resident has been trying to exit the doors. - An advanced skilled nursing evaluation note dated 05/21/25, resident wanders at night. - A nursing progress note dated 05/22/25, Resident has been up in his wheelchair rolling around and will not stay on pod 1 as it has been asked of him to do that many of times so staff can keep a better eye on him, and he continues to go towards the doors and into other residents' rooms. He is very pleasantly confused. - An advanced skilled nursing evaluation note dated 05/23/25, Resident is confused. Resident is awake at night. Resident wanders at night. - A nursing progress note dated 05/25/25, a family member of one of our patients alerted us to Resident #1 being in the road on [main road off property] we immediately went and got the resident and brought him back in the facility. We brought him back in the facility and placed him on 1 on 1 family member is currently here now and I informed her of his elopement and also that we are trying to find placement for him at a memory care facility. We cannot meet his needs since we are not a lock down facility or have wonder guards to prevent resident from getting out the facility and getting hurt [receiving SNF] has accepted resident and will be transporting him to their facility. - An elopement evaluation progress note dated 05/25/25, Elopement evaluation: History of elopement while at home: Yes. Wandering behavior, a pattern or goal-directed: No. Wanders aimlessly or non-goal-directed: Yes. Wandering behavior likely to affect the safety or well-being of self / others: Yes. Wandering behavior likely to affect the privacy of others: Yes. Recently admitted or re-admitted (within past 30 days) and has not accepted the situation: Yes. Elopement Score: 8.0 Actioned clinical suggestions: [no actions indicated]. - A social services progress note dated 05/25/25, Resident will be transferred to [facility] today due to his need for a secured memory care unit. He will be transported there around 02:00 PM today. [Resident #1's family member ] is aware of this plan and that she can later transfer him to another facility later on if she wishes to. - A nursing progress note dated 05/25/25, d/c'd to another facility. Record review of Resident #1's Discharge summary dated [DATE] reflected:- discharge date : [DATE].- Expected return? No. - Released to other facility.- Reason for discharge: needs a secure memory care unit.- Final summary: Resident is transferring to [facility] a secured memory care unit.Review of Resident #1's discharge planning review record dated 05/25/25 reflected: Who initiated discharge? reflected was marked Facility.If facility, if this was a facility initiated discharge, was advance notice given (either 30 days or as soon as practicable on the reason of the discharge) to the resident, resident representative, and a copy to the Ombudsman; Did the notice include all the required components (reason, effective date, location, appeal rights, Ombudsman, ID, MI info as needed) and was it presented in a manner that could be understood; and if changes were made to the notice, were recipients of the notice updated? Signatures of facility staff on the document included SW and ADON A dated 05/25/25.In an interview on 06/25/25 at 11:16 AM with LVN C she stated she was the charge nurse working with Resident #1 on the day of the elopement on 05/25/25. She stated she was alerted by another nurse and other residents family members who provided a description of seeing a resident out of the facility that matched Resident #1. LVN C stated she then went out of the facility with CNA D to retrieve Resident #1. LVN C stated once they were able to locate Resident #1, he was no longer on the property, and was found down the street that leads up to the facility sitting in his wheelchair next to the main road. LVN C stated they were not sure which door Resident #1 exited from, and that he would frequently need redirecting from trying to leave through doors in other halls leading to the side of the building. LVN C stated if they saw Resident #1 trying to elope, they would attempt to redirect him, but was not aware of any other interventions in place to prevent elopement prior to the incident on 05/25/25. LVN C stated Resident #1 was a known elopement risk based on his care notes which documented each time he wandered and displayed exit seeking behavior. In an interview on 06/25/25 at 11:48 AM with CNA D, she stated she worked with Resident #1 on 05/25/25. She stated that she was alerted by LVN C that Resident #1 had eloped and went out with her to retrieve the resident. She stated they found Resident #1 away from the facility next to a busy road in his wheelchair. CNA D stated they were unsure which door Resident #1 used to leave the facility, but no alarms were heard. CNA D stated police were around, and police asked them (LVN C and CNA D) if Resident #1 was part of their facility; police then released Resident #1 back to them with no further questions. In an interview on 06/25/25 at 12:06 PM with ADON A, he stated he was at the facility on 05/25/25 and was notified of Resident #1's elopement by LVN C after the incident occurred. ADON A stated after Resident #1 was brought back to the facility he was placed on 1:1 until he was discharged later that same day. He stated he was previously aware of Resident #1's elopement risk for a while and they had been trying to get him to a secured facility the week prior but had no takers. He stated after the incident occurred that was when the ADM advised the SW to get him out of this facility and to another facility with a secured unit that day. ADON A stated Resident #1 was not appropriate for this facility and was constantly exit seeking. ADON A stated they should never have accepted him and that due to elopement risk and dementia they were not able to keep him safe. ADON A stated they presently had other residents with a diagnosis of dementia and will keep them as long as they don't try to reach for the door. ADON A stated after the incident they discharged Resident #1 to another facility within a few hours. In an observation and interview 06/25/25 at 01:04 PM with LVN E in the 200 hall (skilled nursing side); the door to the exterior was observed easily pushed open and not secured with the electromagnetic lock. The door alarm was functional and did sound as soon as the door opened. LVN E was observed closing the door and then pushing it open to test the magnetic hold on the door which was not holding allowing the door to easily swing open. LVN E was observed shouting down the hall to other staff telling them to push the button on the lock pad located at the nurse's station. This exchange occurred multiple times as they were observed to have difficulty getting the door to secure. LVN E stated staff were to check that the doors to the exterior were secured each shift. She stated a potential negative outcome of an unsecured door for residents that wander would be residents could get out and the road is right there, they can be harmed from a car or even from someone living at the apartment complex across the street; people are weird nowadays and you never know. In an observation and interview on 06/25/25 at 01:47 PM, observations were made of the exterior doors to the long-term care side of the facility with ADON B. The doors on halls 600 and 700 were observed unsecured when checked. Both doors were observed easily swinging open; no alarm was seen on the door or was heard sounding when the door opened. ADON B stated she was not sure why the doors were unlocked. ADON B was observed going to the nurses' station and pushing the button on the lock pad to secure the doors. ADON B was then observed going back to check the 600 and 700 doors appeared to be secured after pushing the button. ADON B stated she would investigate what occurred to cause the doors to not be secured. In an interview on 06/25/25 at 02:20 PM with ADON B, she stated it was identified the door was not securing because staff were pushing the incorrect button at the nurses' station and did not know the correct way to ensure the doors were locked. She stated the button to release the doors was being pressed instead of the button to secure the doors. She stated by pressing the button to release the doors, it causes all the doors on the long-term care side to be easily opened. ADON B stated she had to complete an in-service with staff to ensure they knew how to secure the doors now that this was identified and presented surveyor with in-service completed. Review of in-service record dated 06/25/25 presented by ADON B reflected topic educate on proper way to lock door. Key on button is to unlock door, round button is to lock door. Review of the facility Wandering and Elopement policy last revised March 2019 reflected: The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. - If identified as a risk of wandering, elopement, or other safety issues the resident care plan will include strategies and interventions to maintain the resident's safety. The Administrator was notified on 06/25/25 at 05:10 PM that an IJ had been identified and an IJ template was provided.The following POR was approved on 06/26/25 at 12:30 PM and reflected the following:Plan of RemovalImmediate Threat [Immediate Jeopardy] On 06/25/2025 an abbreviated survey was initiated at facility. On 06/25/2025 the surveyor provided anImmediate Threat (IT) [Immediate Jeopardy (IJ)] Template notification that the Regulatory Services has determined that thecondition at the facility constitutes an immediate threat to resident health and safety.The notification of Immediate Threat [Immediate Jeopardy] states as follows: F689 - The facility must ensure each resident receivesadequate supervision and assistance devices to prevent accidents.The facility failed to ensure Resident #1 did not exit the facility without staff's knowledge and ambulateapproximately 100 yards down their driveway to a busy street with a speed limit of 65 MPH on 05/25/25.Action: Resident was put on 1:1 service immediately with nursing staff member by facility DON and Admin until asafe placement at a secured facility could be located and resident transferred. All residents' elopement assessmentswere verified that they were up-to-date and that the elopement binders for at risk residents, at both nurse's stationsand the front reception desk, were up to date by Interdisciplinary Team (IDT) team. All exterior facility doors were audited by maintenance for functionality and changed door codes.Completion: 6/25/25On 06/25/2025 the Administrator notified the Medical Director of Immediate Jeopardy. On 06/25/2025,all exit doors throughout the facility were assessed for proper functioning.Action: Facility nursing staff have been re-educated on procedures to unlock and lock exit doors byADON. ADONs were in-serviced by Administrator. Admin was educated by Maintenance upon onorientation of start of position. (Maintenance was educated by prior company.) Any staff who are notworking will be re-educated prior to working their next shift. New staff will be educated on orientation.Any agency nursing staff will have to read and acknowledge the in-service on the staffing portal beforeshift acceptance. Comprehension will be verified by Admin/designee where staff will have to correctlyverbalize back how to properly lock and unlock the door. This will be recorded on the facility in-service log.Start Date: 6/25/25Completion Date: 6/25/25Responsible: AdministratorAction: Facility has placed directions to lock and unlock exit doors in nurse's binder at each nurse'sstationStart Date: 06/25/25Completion Date: 06/25/25Responsible: AdministratorAction: Door locks were tested and reactivated on all exit doors by maintenance on facility monitoringtool.Start Date: 06/25/25Completion Date: 06/25/25Responsible: MaintenanceAction: Facility Nursing Staff continue to check exit doors 3 times per shift to ensure the doors are secureusing facility monitoring tool and will be monitored by ADONs for completion.Start Date: 06/25/25Completion Date: 6/25/25Responsible: AdministratorAction: Maintenance checks facility doors once weekly to ensure exit doors have no maintenance issuespreventing them from securing with facility monitoring tool.Start Date: 06/25/25Completion Date: 06/25/2025Responsible: Maintenance SupervisorAction: The QA Committee will review door alarm logs weekly for 4 weeks, then monthly.Administrator/designee will conduct unannounced door security audits 2 x week for 30 days.Start Date: 06/25/25Completion date: 06/25/25Responsible person: Administrator/designeeThe POR was monitored on 06/26/25 in the following ways: Review of the documentation for door checks on Pods 2 of 2 (both skilled nursing and long term care side) reflected Doors codes have been changed for resident safety. Do not give the code to residents that should not have it. Do not give it to family members verbally in front of residents. Listen for the alarm. Alarm for front door is reset by a button at Pod 1. You are responsible for checking the doors at least 3 times per shift to make sure front door is secured as well as the doors to your pod. You must do these rounds. No exceptions. These can be done by a nurse or a CNA but must be signed off by whoever completes it. Each of the documents on Pod 1 and Pod 2 (skilled nursing and LTC side) were identified Door check log Pod 1 and Door check log Pod 2. It included a statement, you are responsible for checking all external exit doors on your Pod 3 times per shift as well as the front door 3 times per shift. It can be done by a CNA or nurse. Day shift and night shift. Record reflected it was logged with a date, time, and signature by staff multiple times a day beginning 05/25/25 and daily through 06/26/25.Review of an in-service sheet dated 06/25/25 presented by ADM/ IDT reflected to lock doors hit circle button, to unlock doors hit the key. Directions also in binder at both nurses' stations- competency: must verbally repeat back to educator. This included various staff from different positions including laundry, dietary, nursing, housekeeping, and admin staff such as MDS, marketing, activity director etc. Included both pods. 83 staff observed have either signed off physically or were marked as completed over the phone.Review completed with document dated 06/25/25 for door audits by maintenance all exit door locks were tested and reactivated with comments no issues with locks on doors signed by MTA.Record review of QAPI ad hoc dated 06/25/25 reflected: The locks for the facility door must always be engaged. To engage the locks follow these steps: - To unlock door push the button with the key emblem- To lock press the circle button - Residents with high elopement risks should not be outside of the facility without proper supervision and you can find the resident with high elopement risks in the elopement binders at both nurses station. If a resident is leaving the facility they need to sign out at the front desk.Document included attendance and signature by ADM, ADON A, medical director via phone, BOM, SW, MDS LVN, treatment nurse, admissions, human resources, and activity director. Record review of blank logs created for maintenance/designee for weekly audits of the door. check all exterior doors for any maintenance issues that would prevent them from securing. Created for ongoing audits. An observation and record review on 06/26/25 at 02:41 PM at nurses stations observed binders that contained instructions on locking the doors. Binder reflected How to lock/unlock doors- to unlock the doors press the button with the key emblem, to engage the locks press the circle button. A bright yellow document was also placed near the lock pads that reflected:Door locks- Doors should remain locked. If visitors buzz for entrance a staff member must walk to the front, open the entrance and verify they log into visitor log. - Locking access from the nurses station must be engaged. At any time if the button is pressed with key picture on it, it unlocks multiple doors. The round reset button must be pushed to relock the doors. - In other words, if you press the key button to unlock then you must hit the reset button to relock the doors. - Keeping the doors locked is not optional. In an interview and observation on 06/26/25 at 02:41 PM with LVN F she stated she arrived at 05:30 AM for her shift and was updated by the night shift nurse on the procedure to secure the door. LVN F stated she had already also received in-service via text 06/25/25 and had to verbalize understanding over how to secure the doors and elopements. She stated interventions other than redirection for residents who are exit seeking would include make sure exterior doors are closed and secured and check rooms to ensure you know where residents are at all times. She stated if residents are exit seeking they should also be moved closer to the nurses station for observation or placed on 1:1 care. She stated residents located in the elopement binders will get extra attention to ensure they are in their rooms or monitored while out of their rooms. LVN F stated a potential negative outcome in failing to supervise residents or failing to secure the doors would be this facility is near a highway and something bad could happen to them. LVN F was able to identify the abuse coordinator and also confirmed training on abuse and neglect. LVN F was observed locating the binder that contained information on securing the doors, as well as pressing the correct button to secure the doors . In an interview and observation on 06/26/25 at 02:50 PM with CNA G she stated she was an agency staff member but worked at the facility often. She stated she received in-service 06/25/25 and additional training 06/26/25. She stated the training covered ensuring the doors were secured, how to secure them, and elopements. She stated the training was provided to her by ADON B. CNA G stated she would be able to identify if the door is secured by the green light above the door near the magnetic strip. She stated if the light was green that would mean it was secured and that the door will also make noise if it was unsecured. CNA G stated anytime she was at the nurses station she has made it a habit to press the button to ensure the doors were secured. CNA G stated if a resident attempted to elope she would redirect them, provide them education, and would notify the charge nurse right away. CNA G stated she would find information on securing the doors in the binder located at the nurses station. She confirmed training on abuse and neglect and was able to identify the abuse coordinator as the ADM. CNA G was observed correctly demonstrating which button secured the doors. CNA G stated if she needed to identify who was an elopement risk she would look at the elopement binder located at the nurses station. In an interview on 06/26/25 at 03:02 PM with RN H he stated he was an RN charge nurse. He stated he received training on 06/25/25 via a text message on securing the doors/ elopements and was asked to let them know he understood the material. He stated on 06/26/25 he also observed the doors and was shown how to properly secure them. RN H stated if he witnessed exit seeking behavior he would redirect the resident that was exit seeking, keep them within view and safe distance from doors. RN H stated if anyone needed to identify someone who was an elopement risk they can do so by reviewing the elopement risk binder kept at the nurses station. RN H was able to successfully explain to surveyor the proper way to secure the door via the lock pad at the nurses station. In an interview on 06/26/25 at 03:08 PM with MA I, she stated she was both a medication aide and CNA. She stated she was in-serviced 06/26/25 by the ADONs on elopement and securing the doors (how to properly ensure they are secured). MA I stated if a resident shows exit seeking behavior she has been taught to give them distractions and redirect, provide them with activities, or give them food/snacks. MA I stated if a resident was able to get out she would notify the ADM immediately and ensure she was at the residents side at all times to ensure safety while they were redirected back. MA I confirmed she was also trained on abuse and neglect, and was able to identify the ADM as the abuse coordinator. MA I was able to successfully explain to surveyor the proper way to secure the door via the lock pad at the nurses station.In an interview on 06/26/25 at 03:16 PM with HK J he stated he received training 06/25/25 by MTA on ensuring that doors are secured at all times and not opened. HK J stated if he observed any door that was unsecured he would immediately report it to the ADM or MTA. HK J stated he has also received training on abuse and neglect and provided examples. He stated the abuse coordinator was the ADM. In an interview on 06/26/25 at 03:20 PM with MA K she stated she received training that covered elopements and the doors being secured. MA K stated she gets very involved in the care of the residents so when she received the text message with the inservice information she called and asked what happened, wanted to ensure she obtained all the information needed to prevent it from occurring again. MA K stated she was a seasoned employee and would often train others or let others know who was an elopement risk. She stated there was also an elopement binder at the nurses station if you wanted to see that information. MA K stated she was trained to always check the doors to the exterior to ensure they were secured. If a resident was exit seeking to monitor them, provide redirection, check on them more frequently, and provide activities or keep them entertained. MA K stated she was also observed by ADONs checking the door and working the keypad to demonstrate understanding. MA K was able to successfully explain to surveyor the proper way to secure the door via the lock pad at the nurses station.In an interview on 06/26/25 at 03:28 PM with CNA L, she stated she received training on elopements and door security on 06/26/25 by ADON A. She stated she would make sure the light above the door was green to ensure it was locked. She stated the doors need to be checked to ensure they are secured. CNA L was able to describe how to properly secure the door and how to redirect a resident who was an elopement risk. She stated if a resident was exit seeking, she would report it to the charge nurse immediately after redirecting and ensuring the resident was safe. In an interview on 06/26/25 at 03:32 PM with ADON A, he stated he remained at the facility late 06/25/25 in order to receive training presented by the ADM on door security. He stated after training was completed on department heads they then went back and provided training to their direct staff. He stated it was his expectation that the side doors are not to be used at all unless of an emergency. He stated he expected that staff were to check them frequently and ensure they were secured through observation of the green light above the door. ADON A stated if residents begin to show exit seeking behavior he would expect that an updated elopement assessment was completed, to document the behavior in the nursing progress notes and monitor it for 3 days and ensure they are moved to a more appropriate facility if they need to. ADON A stated it was his expectation that staff redirect residents, provide activities, or try snacks to distract them. He stated both new and agency staff will be oriented and in-service on the expectations on ensuring the doors are secured, how to secure them, and elopement procedures. In an interview on 06/26/25 at 02:41 PM with the FD , she stated she received training both 06/25/25 and 06/26/26 on elopements (what to do) and securing the doors (how to properly secure them). She stated the training was presented to her by the ADM. She stated she also had a book at the front desk that indicated which residents were an elopement risks and would have to refer to it to ensure none of them were able to get out. She stated she would also ensure that all residents were properly signed out if going on pass to ensure all residents were accounted for. FD was able to explain how to correctly secure the door and explained the importance of ensuring all visitors and residents entering and exiting from the front were logging in and documented. In an interview and observation on 06/26/25 at 03:49 PM with MTA, observations were made of all exterior doors to ensure they were secured, had a functional electromagnetic lock, and alarm. The doors that were previously unsecured were e confirmed secured. The MTA stated staff should ensure the doors remained secured through regular checks. He stated he also was to complete a weekly audit of the doors magnets to ensure they were functional and hold. The MTA stated only during a fire when the fire alarm is pulled should all the doors release. The MTA stated he had knowledge on the proper way to secure the doors and provided that information to the ADM and department heads so that they could train all staff and ensure they were pressing the correct button to secure the door. In an interview on 06/26/25 at 04:18 PM with the ADM, she stated she can confirm that all staff had received training on elopements and the proper way to secure a door/ ensuring they are secured. She stated they had staff confirm they understood the material through verbal confirmation. She stated education was provided to everyone across different areas to include nursing, housekeeping, dietary, etc. The ADM stated agency staff had a form on the portal that would provide them with education on these topics prior to working, and that her new hire staff will also have it as part of their orientation in the new hire packet. The Administrator was informed the immediacy was removed on 06/26/25 at 05:20 PM. The facility remained out of compliance at a scope of isolated at a severity level of no actual harm that was not immediate due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of four residents reviewed for quality of care. The facility failed to assess and put treatment orders in place when Resident #1 developed a rash under her abdominal fold causing her excruciating pain. These failures placed residents at risk of improper wound management, the development of new skin integrity issues, deterioration in existing skin integrity, infection, and pain. Findings included: Review of Resident #1's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dermatitis (skin conditions), type II diabetes, reduced mobility, morbid obesity, and muscle wasting and atrophy (wasting away). Review of Resident #1's quarterly MDS assessment, dated 08/26/24, reflected a BIMS score of 10, indicating she was moderately cognitively impaired. Section M (Skin Conditions) reflected she was at risk of developing pressure ulcers/injuries. Review of Resident #1's quarterly care plan, dated 11/01/24, reflected she was at risk for pressure ulcers due to impaired mobility with an intervention of conducting a skin assessment and inspection every shift. Review of Resident #1's skin assessment, dated 11/19/24 and created by LVN A, reflected no new skin issues noted. Review of Resident #1's physician orders, on 11/22/24, reflected no orders for skin treatments. Review of Resident #1's physician orders, on 11/25/24, reflected an order dated 11/22/24 for Nystop (an antifungal powder) - 100,000 unit/gram - apply small amount to resident skin fold three times a day until healed for moisture accumulation. During an observation and interview on 11/22/24 at 2:15 PM, Resident #1 asked to speak with this Surveyor. She stated over a week ago, a CNA at night (did not remember her name) tore off her brief too fast and the Velcro got stuck on her skin and ripped it. She stated it bled for at least four days and a nurse had not assessed her until that day (11/22/24) when they put some kind of powder on it. She opened her brief which revealed an irritated red rash under her abdominal fold. Resident #1 grimaced and winced in pain when she picked up her abdominal fold to show the irritated area. CNA B entered the room and stated the red area to Resident #1 had been there for at least two weeks. She stated she had been telling nurses and no one had assessed her until that day (11/22/24) when she requested LVN C to look at it. She stated at that time, LVN C applied Nystatin powder to the area. She stated she believed Resident #1 needed to be assessed by the WCN. She stated that day (11/22/24) Resident #1 had been in the most pain from the area as she would have tears in her eyes when she rolled her over to provide incontinent care. Resident #1 stated it made her feel like she was not a priority. During an interview on 11/22/24 at 3:18 PM, LVN C stated today (11/22/24) was her first actual day working at the facility. She stated CNA B asked her to look at Resident #1's skin earlier in the day and stated the area should have been assessed long before that day. She stated she left a note for the WCN so it could be further assessed. She stated she applied Nystatin powder because it appeared to be a fungal rash. During a telephone interview on 11/22/24 at 3:47 PM, Resident #1's RP stated he visited her every single day. He stated the redness to her skin happened at least a week ago. He stated an aide snatched the brief off her and the Velcro scraped her skin. He stated they had not been able to get a nurse to look at it and she had been in a lot of pain. He stated the area was getting worse daily. During an interview on 11/22/24 at 4:00 PM, LVN A stated on 11/19/24 she and the ADON did a skin sweep (skin assessments) on all residents in the facility. She stated the ADON did Resident #1's actual skin assessment and she just signed off on it. She stated she did not remember if the ADON told her she had any skin integrity issues. During a telephone interview on 11/23/24 at 9:10 AM, the ADON stated she and LVN A did a lot of skin assessments together on 11/19/24. She stated she could not recall if Resident #1 had any new skin integrity issues. She stated Resident #1 did not have a history of a rash but did remember her having some redness to her abdominal folds at the beginning of October (2024). She stated she was not sure if she had treatment orders in place or if she was being seen by the WCN or WCD. During a telephone interview on 11/23/24 at 9:16 AM, the WCN stated she had not been notified about any skin issues for Resident #1. She stated her expectations were that the nurses notify her of any new skin integrity issues for all residents as that was the procedure. She stated if she had been aware, she would have assessed her and would have absolutely put treatment orders in place. During a telephone interview on 11/23/24 at 9:25 AM, the WCD stated he had not been notified of any skin issues regarding Resident #1. He stated his expectations were that all skin integrity issues were relayed to the WCN. During a telephone interview on 11/25/24 at 10:58 AM, the DON stated she was notified of redness to Resident #1's skin on 11/22/24 and a nurse assessed it. She stated their WCN assessed it over the weekend and their WCD was at the facility that day (11/25/24). She stated if no new skin issues had been marked on the skin assessment on 11/19/24 , it could mean the redness was not a new issue. She stated her expectation was that it should have been relayed to the WCN so she could assess the area and contact the WCD or NP to get orders if they chose to. She stated not providing treatment could cause worsening of skin issues. Review of the facility's Prevention of Pressure Injuries Policy, dated April 2020, reflected the following: The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors. Preparation Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors, and prior to discharge. . 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema ). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Monitoring 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis.

Based on observations, interviews and record reviews, the facility failed to ensure each resident had the right to be free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to ensure Resident #1 was safe from sexual abuse. On 02/27/24, Resident #1 alleged she was sexually assaulted, facility staff transferred her to the hospital, and hospital staff took a sexual assault exam. On 04/16/24, the sexual assault exam results showed a presence of semen in Resident #1's brief and on and in her vagina. An IJ was identified on 05/10/24. The IJ template was provided to the facility on [DATE] at 6:24 p.m. While the IJ was removed on 05/13/24, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injury, harm, psychosocial harm, and a decreased quality of life. Findings included: Record review of Resident #1's face sheet, dated 04/18/24, revealed a 73-years old female who was admitted to the facility on [DATE], readmitted on [DATE], had an RP, and had diagnoses including unspecified dementia (A group of thinking and social symptoms that interferes with daily functioning) that was mild, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, unspecified sequelae of cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), generalized anxiety disorder, contracture (A permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff) of muscle unspecified lower leg, difficulty in walking, unspecified single episode unspecified major depressive disorder, other reduced mobility, right and left knee contracture, weakness, unspecified altered mental status, cognitive communication deficit, and generalized muscle weakness. Record review of Resident #1's quarterly MDS assessment, dated 04/08/24, revealed a BIMS score of 7, indicating she had severe cognitive impairment. Record review of Resident #1's comprehensive care plan, dated 04/16/24, revealed she was at risk for psychosocial deficits/PTSD related to trauma (sexual assault). Interventions included: female only to provide care, female staff to accompany if male nurse on shift, services from a Licensed Mental Health Provider as indicated, monitor for signs and symptoms of depression, anxiety, eating disorders, sleep disturbances, and substance abuse disorder, psych services visit routinely, staff assist with recovery and avoid traumatization by ensuring immediate safety and addressing physical injuries resulting from the assault, providing medical care, including forensic evidence collection, in a sensitive manner and prioritizing well-being and minimizing further harm, and creating a safe environment for disclosure. Record review of Resident #1's progress notes revealed a note by RN C on 02/27/24 at 8:51 p.m., Resident complained of vaginal pain. Assessed residents peri area. No skin tears, bleeding nor lacerations noted. Hyperpigmentation noted (baseline) with redness from moisture of incontinence. ADON, family aware.' A note by RNC on 02/27/24 at 8:55 p.m., Entered resident room with officer for interview. Family in process of bathing resident. Family instructed to refrain from completing bath until investigation completed related to resident allegation of sexual assault. Interview completed by the officer. EMS contacted for transport for further assessment. A note by RNC on 02/27/24 at 9:55 p.m., Resident transported by EMS. Family awaiting resident at hospital. A note by ADON on 02/27/24 at 11:43 p.m., CNA alerted [ADON] that Resident #1 expressed allegations of sexual assault. Notified ADM and RDO. Law enforcement contacted; family present at time of allegation.; resident currently at hospital for further evaluation. A note by ADON on 02/28/24 at 7:07 p.m., Received nurse to nurse report from Hospital staff at 1907 (7:07 p.m.). According to the report, Resident #1 was clear of signs of sexual assault. Family and resident stated they are comfortable and feel safe related to resident returning to facility. Per report received, Resident #1 has no current complaints of pain or distress, and will be returning to the facility before 8:00 p.m. No new orders expected for Resident #1 post hospital admission. Care plan to continue. Administrator notified; RNC notified. Record review of Resident #1's POC history, from 02/24/24 through 02/27/24, revealed all CNAs who provided ADL care to Resident #1 were female except CNA A, who was a male, provided support to Resident #1 for bed mobility and supervised Resident #1's toileting on 02/26/24 at 4:56 a.m., and observed Resident #1's level of control with bowel and bladder function on 02/26/24 at 5:02 a.m. Record review of Resident #1's vital checks, from 02/26/24 through 02/28/24, revealed all staff who checked and documented vitals taken from Resident #1 were female. Record review of Resident #1's MAR and TAR, from 02/24/24 through 02/27/24, revealed all female staff worked with Resident #1. Record review of the facility's staff schedule, from 02/24/24 through 02/28/24, revealed all female staff worked on the hallway Resident #1 resided on. Record review of the facility's sign in and out sheet, from 02/20/24 through 02/27/24, revealed Resident #1's RP visited her on 02/20/24 at 8:30 p.m., 02/21/24 at 9:53 p.m., 02/23/24 at 2:18 p.m., 02/24/24 at 8:00 p.m., and 02/27/24 at 7:00 p.m. Resident #1's family member also visited her on 02/23/24 at 2:18 p.m. and 02/27/24 at 7:00 p.m. Resident #1 had no other visitors listed. Record review of the facility's provider investigation report, undated, revealed Resident #1 alleged the abuse incident occurred on 02/27/24 at an unknown time in her room. The facility self-reported the incident on 02/27/24 at 8:49 p.m. There was no alleged perpetrator and witnesses listed. The investigation summary stated, On 02/27/24, Resident #1 told CNA B and RP that she had been raped by two men. CNA B notified the ADON and the ADON went and spoke further to Resident #1. Resident #1 at this time told the ADON that it was 2 men, 1 light skinned and 1 dark skinned, but that she did not know what time it happened at. Resident #1 was asked if she wanted to go to the hospital for further examination and Resident #1 at this time stated no. RN C did complete assessment and nothing from baseline noted. Once PD arrived, Resident #1 did give more information to officers with RN C present. When asked what occurred, Resident #1 stated that 1 guy came in and was talking dirty to her and a 2nd man came in and they were talking. Resident #1 was asked what happened next and she stated that one turned her on her side and put his penis inside her, Resident #1 also stated both had put their penis inside her but it did not hurt and they got busy but not too fast. When asked for a description of the men, Resident #1 stated 1 was a little guy, light skinned in his 20's and the other was a big guy dark skinned in his 30's. When asked if they worked here at the facility, Resident #1 stated no. When asked if they were wearing scrubs or regular clothes, Resident #1 said regular clothes. Resident #1's room was located near nursing station 2 close to the nurses station and staff on pod 2 were interviewed by the ADON and staff did not see anyone with the description that was given on the two males. After interview with Resident #1, staff assisted with placing brief and hospital gown and RP left to meet Resident #1 at the hospital. Resident #1 was transferred to the hospital for further evaluation and a SANE exam. The ADON spoke to a hospital staff member, who stated Resident #1 was clear of signs of sexual assault, RP and Resident #1 stated to the ADON that they felt safe at the facility. Resident safe surveys were completed for all female residents on 02/27/24 and revealed all residents indicated they never been inappropriately touched in the facility, never seen anyone being inappropriately touched in the facility, knew who to report abuse and neglect to, and felt safe living at the facility. Staff in-services were also initiated by the ADON on 02/27/24 and revealed staff were retrained on abuse and neglect reporting and preventing. MD and Ombudsman were also notified on 02/27/24. The investigation findings were unfounded. Staff statements attached to the report revealed ADON interviewed four CNAs on the evening of 02/27/24, who were all female, and all other staff who worked on the hallways in which Resident #1 resided on and was near, which revealed they did not witness any males matching Resident #1's description of the two alleged perpetrators. RNC and a PD officer also interviewed Resident #1 with RP present on 02/27/24 at 8:55 p.m. RP was bathing her even though they were instructed not to bathe Resident #1. RP indicated they did not bathe any of Resident #1's private areas, only her top half. Statement given by Resident #1 in response to questions by PD officer were also attached and stated the following: Can you tell me what occurred? 1 guy came into room and was talking dirty to me. A 2nd man came in and they were talking. Do you know if they work here? they said they don't work here What happened next? one turned me [Resident #1] on my side and put his penis inside me Did both men put their penis in you? yes, it didn't hurt and they got busy but not too fast Did they finish? I think so Do you think they were wearing a condom? I don't know Were they wearing scrubs or regular clothes? regular clothes When did this occur? this afternoon Was it before or after your roommate left? after Can you describe them? 1 was little guy, light skinned. 1 was big guy dark skinned Do you know what age they appeared? little guy 20's, big guy 30's How was their hair? poofy During an interview on 03/08/24 at 1:27 p.m., Resident #1 revealed a tall dark-skinned male and short light-skinned male came into her room and sexually assaulted her. Resident #1 could not recall what the alleged perpetrator(s) wore and if they were visitors or staff. Resident #1 stated there were no staff in her room and her roommate was not in her room around the time of the incident. Resident #1 also stated staff last checked on her on 02/27/24 at 3:00 p.m Resident #1 could not remember the nurse or nurse aide who checked on her on 02/27/24 at 3:00 p.m. Resident #1 stated she never been sexually assaulted at the facility in the past. Resident #1 also stated she felt safe at the facility at the time of the interview. Resident #1 stated she had no concerns or issues about how staff handled the incident. Resident #1 also stated staff checked on her often. Resident #1 also stated her RP was notified of the incident. The interview was stopped because Resident #1 began to cry and was unable to answer any additional questions. An observation of the front entrance on 04/18/24 at 9:05 a.m. revealed the front entrance doors automatically opened by motion sensors. The inside of the front entrance had a keypad. The receptionist was not at the front desk. There was a camera mounted on one of the walls in the front entrance area that was blinking a green light and angled at the front entrance doors. There was a sign in and out sheet that visitors were signing before entering further into the facility. During an interview on 04/18/24 at 9:26 a.m., the ADM revealed the hospital notified staff that they did not find any results of sexual assault on Resident #1 on 02/27/24. The ADM explained the hospital staff swabbed Resident #1 and sent the sexual exam kit to the crime lab to be examined on 02/27/24. The ADM went on to explain that due to the delay in lab results because of the state's backlog, the PD received and notified the facility of the semen found in and on Resident #1 and in Resident #1's brief on 04/16/24. The ADM stated staff initiated resident safety surveys, trauma assessment on Resident #1, employee questionnaires, and in-services on abuse again after PD's notification of the sexual assault exam results. The ADM also stated a Quality Assurance meeting was arranged to discuss interventions to implement after the PD's notification of the sexual exam results in addition to the interventions implemented after Resident #1 reported the allegation on 02/27/24. The ADM also stated staff revised Resident #1's care plan to reflect Resident #1 would receive care and services from female-only caregivers. The ADM stated Resident #1's roommate told her that she felt safe at the facility, did not see anything, and did not see anything happen to Resident #1 on 02/27/24. The ADM also stated all female staff worked with Resident #1 on the day of the incident (02/27/24). The ADM stated while there were cameras in the area near Resident #1's room, the cameras were aimed at the nursing station and did not record because they were set to stream live feed. The ADM also stated staff interviewed Resident #1 again after the PD's notification of the sexual exam results, who had a similar recollection of the incident as compared to her recollection on 02/27/24. The ADM stated Resident #1 was not at the facility because the MD recommended to send her to the hospital again for another DNA test collection after staff notified the MD of the sexual assault exam results. The ADM stated Resident #1's RP initially did not want Resident #1 to go to hospital again, did not explain why and later agreed to send Resident #1 to the hospital because they did not want staff to document that they were refusing to seek medical attention for Resident #1 on 04/17/24. Her and staff did not know if Resident #1 provided another DNA sample at the hospital on 04/17/24 and hospital staff did not inform them if Resident #1 agreed to provide another sample. The ADM stated the PD informed her that all male staff except three male staff members volunteered to provide a DNA sample, did not indicate who were the three male staff who refused to volunteer, and there were three male staff who were unable to provide their DNA sample until 04/19/24. The ADM stated Resident #1's RP and a male family member were in Resident #1's room on 02/27/24. The ADM explained the RNC and PD observed Resident #1's RP showering Resident #1 on 02/27/24, stopped the RP from showering Resident #1, and explained to the RP that they needed to collect a sample of Resident #1's DNA. The ADM went on to explain the RP told staff that she continued to shower Resident #1 because she wanted Resident #1 to feel clean. During an interview on 04/18/24 at 10:24 a.m., Resident #1's RP revealed Resident #1 has been at the hospital since 04/17/24. RP questioned why she was not directly notified by the State Agency of Resident #1's incident, why the State Agency did not wait for the PD's sexual exam results before unsubstantiating Resident #1's allegations during the surveyor's initial visit on 03/08/24, and alleged the facility refused to provide her with their policies and procedures and investigation of the incident. When an attempt to ask the RP questions about her and a male family member visiting Resident #1 on the day Resident #1's alleged she was sexually assaulted on 02/27/24 was made, the RP stated that she was not in the mental state to answer any questions, was dealing with a lot, stated that she might be in a better headspace around 2:00 p.m. or 3:00 p.m. and advised to call back around 2:00 p.m. or 3:00 p.m. because she had questions to ask and to answer questions. RP abruptly ended the call because she was receiving another call. During an interview on 04/18/24 at 11:41 a.m., RNC revealed Resident #1's roommate left to the hospital on 02/27/24 at 3:30 p.m. RNC stated she informed the ADON to inform Resident #1's RP not to bathe Resident #1 after Resident #1 reported her allegation to staff and to have a nurse assess Resident #1 on 02/27/24. RNC also stated her, and the PD walked into Resident #1's room and observed Resident #1 lying in bed, undressed and being bathed by RP. RNC stated there was a male family member also present in Resident #1's room at the time. RNC explained Resident #1's RP told her and the PD that she was informed by the ADON not to bathe Resident #1 but continued to bathe Resident #1 because she wanted Resident #1 to feel clean. RNC explained Resident #1's RP was also adamant about Resident #1 not going out to hospital before the PD arrived at the facility on 02/27/24 and Resident #1 agreed to go to the hospital after the PD directly asked her if she wanted to go. During an interview on 04/18/24 at 12:15 p.m., RNC revealed a male family member visited Resident #1 a few times. RNC did not know if the three staff members worked in the facility after PD notified them of Resident #1's sexual assault exam results and if there have been any positive matches from the DNA samples collected. During an interview on 04/18/24 at 12:22 p.m., the ADM revealed she had not received any notifications from the PD regarding any positive matches from the DNA samples collected. During an interview on 04/18/24 at 12:31 p.m., the ADON revealed she could not remember who the CNA was who notified her of Resident #1's allegation and if she were the first person the CNA notified on 02/27/24. The ADON also revealed RN C might have been the staff member who notified her of Resident #1's allegation on 02/27/24 between 8:20p.m. and 8:30 p.m. The ADON explained she entered Resident #1's room and observed Resident #1's RP and a male family member in the room before RP began to give Resident #1 a shower. The ADON stated she informed Resident #1's RP not to shower Resident #1 because a nurse needed to assess Resident #1, the PD were on their way to interview Resident #1, and Resident #1 was going to be sent to the hospital for an evaluation. The ADON stated Resident #1's RP continued to give a bed bath to Resident #1 despite being told to wait. The ADON expressed something did not sit right with her about the male family member who was in Resident #1's room because she observed him linger while Resident #1's brief was changed. The ADON explained the male family member normally stepped out the room when incontinent care took place. The ADON explained she asked the male family member if he wanted to step out the room and the male family member stayed in there, did not explain why and stated, No I'm good. The ADON further explained the male family member also never hung around Resident #1's bed until 02/27/24. During an interview on 04/18/24 at 12:35 p.m., the ADM clarified four male staff have not provided a DNA sample because they were not working on the day the initial sample was collected and were scheduled to provide a sample on 04/19/24. During an interview on 04/18/24 at 12:41 p.m., the ADM revealed no male staff worked at the nursing station near Resident #1's room because the facility did not have many male staff and after PD notified them of the sexual assault exam results. The ADM stated she was not present when Resident #1 reported the allegation on 02/27/24. The ADM expressed she thought it was odd Resident #1's RP was not upset on 02/27/24, was adamant about not wanting Resident #1 to go to the hospital on 02/27/24 and told her that Resident #1 would not have been sent to the hospital again if she (ADM) had been at the facility on 04/17/24. During an interview on 04/18/24 at 1:06 p.m., RNC revealed it struck her odd Resident #1's RP continued to bathe Resident #1 despite staff telling her not to because Resident #1's POC (Resident records) revealed staff showered Resident #1 earlier in the day of 02/27/24. RNC also stated it struck her odd that Resident #1's RP did not initially want Resident #1 to go to the hospital on 02/27/24. During an interview on 04/18/24 at 2:27 p.m., CNA B revealed on 02/27/24 during the 2:00 p.m. through 10:00 p.m. shift, she checked on and asked Resident #1 if she was doing okay, Resident #1 told her no, she asked Resident #1 why, Resident #1 told her that she had been raped, and she asked Resident #1 who sexually assaulted her, and Resident #1 told her two Black males. CNA B also stated Resident #1's RP and the male family member were not in room at the time Resident #1 alleged she was sexually assaulted. The can explained she immediately went to the ADON and reported Resident #1's allegation before dinner time, (CNA B indicated dinner time was between 5:00 p.m. and 6:00 p.m.). CNA B went on to explain her and CNA D performed incontinent care on Resident #1 after Resident #1 finished eating dinner. CNA B stated she observed Resident #1 was not wet during incontinent care. CNA B also stated Resident #1's RP and the male family member came in Resident #1's room [ROOM NUMBER] minutes after her and CNA D finished performing incontinent care on Resident #1. CNA B stated she was in the room when Resident #1's RP asked Resident #1 how she was doing, and Resident #1 told her RP that she had been raped. CNA B stated Resident #1's RP knew Resident #1 was confused and asked Resident #1 if she really got raped. CNA B could not remember if Resident #1's RP then went to look for the ADON or asked her to bring the ADON to her. CNA B explained she was at the nursing station with RN C when the male family member came and stated nobody could have touched Resident #1 because Resident #1's legs would have been broken. CNA B stated the ADON had RN C assessed Resident #1. CNA B could not remember if Resident #1's RP proceeded to bathe Resident #1 before or after RN C assessed Resident #1. CNA B stated the PD might have not stopped Resident #1's RP from finishing Resident #1's bath. CNA B stated she observed the male family member bringing Resident #1's RP bath supplies while the RP bathed Resident #1. CNA B explained she was not in the room when Resident #1's RP bathed Resident #1. CNA B stated she had never seen the male family member prior to 02/27/24. An attempt to contact Resident #1's RP was made on 04/18/24 at 3:12 p.m. A voicemail and call back number. Resident #1's RP did not return the call prior to exit. An attempt to contact the PD was made on 04/18/24 at 4:02 p.m. A voicemail and call back number was left. During an interview on 04/18/24 at 4:09 p.m., the ADM revealed PD asked to review the facility's video cameras aimed at the nursing station. The ADM explained PD were unable to review the video cameras because the cameras streamed live feed and did not record. The ADM stated she discussed with Resident #1's RP about Resident #1's right to install a camera in her room for video monitoring if Resident #1's roommate consented, managers conducted daily rounds and asked residents if they felt safe at the facility, and all female residents were interviewed on 02/27/24 and 04/17/24. The ADM also stated the receptionist desk had a visitor sign in and out sheet that was implemented before the alleged incident on 02/27/24. An attempt to contact RN C was made on 04/18/24 at 4:24 p. m. A voicemail and call back number was left. RN C did not return the call prior to exit. An observation of the front entrance on 04/19/24 at 9:20 a.m. revealed the receptionist was not at the front desk. There was also a sign in and out sheet that visitors were signing before entering further into the facility. During an interview on 04/19/24 at 9:28 a.m., the PD revealed she had the hospital conduct the SANE exam on Resident #1 on 02/27/24. The PD stated Resident #1's recollection of her allegation on 04/17/24 was the same as what she informed PD on 02/27/24. The PD also stated Resident #1's SANE exam found Resident #1 had semen in her vagina, on her vagina, and in her brief. The PD stated Resident #1's family told them that Resident #1 did not go out on pass and never left the facility since her readmission on 10/20/20. The PD also stated all male staff except three agreed to volunteer in providing and testing their DNA to rule them out as the alleged perpetrator(s). The PD explained of the three staff who denied, two staff did not explain why they did not want to volunteer and one denied due to personal and political beliefs. The PD stated there were three male staff who were going to give a sample of their DNA on 04/19/24 because they were not in the facility when the initial sample collection was taken. The PD also stated they were waiting on Resident #1's second DNA sample to be tested and determine if the semen belonged to more than one male. The PD stated the Maintenance Director informed her that there was no camera footage to review because the cameras streamed on a live feed and did not record. The PD also stated Resident #1's RP told her that she was willing to send Resident #1 to the hospital on 04/17/24 after she was notified of Resident #1's SANE exam results. The PD was unable to provide a copy of the SANE exam results because Resident #1's criminal investigation was ongoing. The PD informed the surveyor that they would email the surveyor a confirmation that they reviewed Resident #1's SANE exam and the results were positive. Record review of an email from the PD, dated 04/19/24 at 10:30 a.m., revealed the following, Hello, I am the Detective who's assigned the case pertaining to [Resident #1]. During our investigation, swabs from [Resident #1's] sexual assault exam were sent to the Crime Lab and came back with the presence of semen being positive in her vaginal swabs and in the crotch of her [brief]. Our investigation will remain open, and we will continue our investigation until the suspect/suspects are found. During an interview on 04/19/24 at 11:23 a.m., the ADM revealed residents and residents' family/RP had the keypad code for the front entrance. The ADM explained there were no restricted visiting hours because residents have the right to have visitors whenever they wanted. The ADM further explained the front entrance doors remained unlocked during the hours the receptionist occupied the front desk and were locked outside the receptionist's hours. During an interview on 04/19/24 at 11:28 a.m., the Receptionist revealed she worked Monday through Friday from 8:00 a.m. through 5:00 p.m. The Receptionist stated there were managers on duty who worked during the weekends at the front desk. The Receptionist also stated the front entrance door was locked outside her working hours. The Receptionist explained visitors would use the intercom system, which notified the nursing stations when there was a visitor and the nursing station had access to unlock the front door entrance. The Receptionist further explained residents and residents' family/RP also had the keypad code to unlock the front entrance door. During an interview on 04/19/24 at 11:35 a.m., CNA D revealed she never had a resident allege they were sexually abused. CNA D stated she reported to a nurse or the ADM if she received any reports related to abuse. CNA D stated she checked on residents every two hours. CNA D stated she never worked with Resident #1. CNA D also stated she never popped into a resident's room whenever residents' had family/RP in the room because she tried to give them space, but she did pop in to ensure residents were doing okay. CNA D did not know if the cameras aimed at the nursing station near Resident #1's room worked. CNA D stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours. An observation of the nursing station near Resident #1's room on 04/19/24 at 11:40 a.m. revealed there were two cameras mounted and aimed at the nursing station. There were also three staff occupying the nursing station. During an interview on 04/19/24 at 11:42 a.m., CNA E revealed she never had a resident allege they were sexually abused. CNA E stated she reported to human resources if she received any reports related to abuse. CNA E stated she checked on residents every two hours. CNA E stated she worked with Resident #1 and Resident #1 never reported abuse to her. CNA E also stated she had only seen Resident #1's RP visit and in Resident #1's room. CNA E explained she has never seen a male visit Resident #1 or in Resident #1's room. CNA E stated she popped into residents' rooms whenever residents' family/RP were in the room. CNA E did not know if the cameras aimed at the nursing station near Resident #1's room worked. CNA E stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours. During an interview on 04/19/24 at 11:49 a.m., CNA F revealed she worked at the facility for one month. CNA F stated she never had a resident allege they were sexually abused. CNA F also stated she reported to the ADM if she received any reports related to abuse. CNA F stated she checked on residents in their rooms every two hours. CNA F did not know if the cameras aimed at the nursing station near Resident #1's room worked. CNA F also stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours. During an interview on 04/19/24 at 11:55 a.m., Resident #2 revealed she was Resident #1's roommate. Resident #2 stated she often observed Resident #1 scream all night and staff did not see or check on her or Resident #1. Resident #2 stated Resident #1 told staff someone came, pulled her clothes down and raped her. Resident #2 could not remember what day Resident #1 told staff about the incident. Resident #2 stated Resident #1 started telling her about the rape two weeks ago. Resident #2 stated Resident #1 never told her who raped her. Resident #2 also stated Resident #1's RP and a male family member visited Resident #1. Resident #2 stated she did not observe anything happen to Resident #1 because she often went out the room. Resident #2 stated she never observed any males come into her and Resident #1's shared room other than the male family member who visited Resident #1. Resident #2 also stated she never observed any male residents come into her and Resident #1's shared room. During an interview on 04/19/24 at 12:12 p.m., Charge Nurse G revealed she never had a resident allege they were sexually abused. Charge Nurse G stated she also has never seen any male caregivers work in the hallways or nursing station near Resident #1's room. Charge Nurse G also stated she reported to the ADM if she received any reports related to abuse. Charge Nurse G stated she checked on residents in their rooms every two hours. Charge Nurse G also stated she had CNAs round when they first come in and start their shifts, during their shifts, and just before the end of their shifts. Charge Nurse G stated there were no gaps in staff coverage. Charge Nurse G also stated she never observed visitors in Resident #1's room. Charge Nurse G did not know if the cameras aimed at the nursing station near Resident #1's room were in operable condition. Charge Nurse G stated the front entrance door had an intercom system that notified staff at the nursing station if there were visitors outside normal business hours and staff had access from the nursing station to unlock the front entrance door. During an interview on 04/19/24 at 12:13 p.m., Charge Nurse H revealed Resident #1 alleged on 04/17/24 that she was sexually assaulted by two white men and explained that one male fingered her, and the other male watched. Charge Nurse H stated Resident #1 had an altered mental status. Charge Nurse H also stated she had never seen any male caregivers work on the hallways or nursing station near Resident #1's room. Charge Nurse H stated she reported to the ADM if she received any reports related to abuse. Charge Nurse H stated she checked on resident in room every two hours. Charge Nurse H stated she had CNAs round when they first come in and start their shifts, during their shifts, and just before the end of their shifts. Charge Nurse H stated there were no gaps in staff coverage. Charge Nurse H also stated she had never observed visitors in Residen [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure that the residents' environment remained as free of accident hazards as was possible in 6 (room [ROOM NUMBER], 504, 506, 701, 707, and 801) of 38 resident room sinks and 1 (600 Hall Shower) of 2 resident shower rooms reviewed for hot water in the facility's 500 - 800 hallways. The facility failed to maintain resident use hot water at safe and comfortable temperatures (between 100-110). Resident use hot water was not reliably controlled and ranged from between 117.1 F and 145.0 F in reviewed locations. These failures resulted in an Immediate Jeopardy (IJ) situation on 03/12/2024. While the IJ was removed on 03/13/2024 the facility remained out of compliance at a severity level of no actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. This failure could place residents at risk for sustaining scalding injuries when using resident-use / resident accessible hot water. Findings included: Review of Resident #73's Face Sheet dated 02/21/2024 reflected that she was admitted to the facility on [DATE] with the following diagnosis: NSTEMI (less severe form of a heart attack because it inflicts less damage to the heart) and Dementia (impaired ability to remember, think, or make decisions that interfere with doing everyday activities). Review of Quarterly MDS Assessment for Resident #73 dated 11/18/2023 reflected a BIMS score of 9 indicating moderate cognitive impairment. Review of Resident #68's Face sheet dated 02/22/2024 reflected that he was admitted to the facility on [DATE] with the following diagnosis: Vascular Dementia (problems with reasoning, planning, judgement, memory and other thought processes caused by brain damage from impaired blood flow to the brain), Acute Congestive Heart Failure (the heart is beating but cannot deliver enough oxygen to meet the body's needs). Review of the Annual MDS Assessment for Resident #68 dated 10/29/23 reflected a BIMS score of 15 indicating normal cognitive abilities. His physical assessment reflected he was independent in performing all his ADLs. Observation on 02/21/2024 at 7:38 AM, the hot water from the sink in room [ROOM NUMBER], which was occupied by Resident #73 was checked with a digital thermometer and found to be 130.5 F. Observation on 02/21/2024 at 8:43 AM, the hot water from the sink in room [ROOM NUMBER], which was occupied by Resident #68 was checked with a digital thermometer and found to be 145.0 F. Observation on 02/21/2024 at 9:50 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 137.3 F. Observation on 02/21/2024 at 9:53 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 117.1 F. The shower head in the room was also checked and found to be 133.5 F. Observation on 02/21/2024 at 9:55 AM, the hot water was checked in the 600-hallway shower room at the shower head with a digital thermometer and found to be 133.5 F. Interview and observation on 02/21/2024 from 10:10 AM until 10:43 AM with the facility's Maintenance Director. The Maintenance Director stated that they want to maintain a safe water temperature in the facility of between 107 F and 110 F. The Maintenance Director stated that they perform water temperature tests of three to four random rooms and try to do so daily or at least every other day. The Maintenance Director stated that if the reading does show high they do not adjust the boiler immediately because the temperatures can fluctuate but will make adjustments if it becomes a pattern and at temperatures of 115 F and above. The Maintenance Director stated that elevated water temperatures could result in skin burns to residents but was not able to state to what degree and exposure time required. The Maintenance Director stated that the facility has two boilers for resident rooms in the 500 - 800 hallways. The Maintenance Director showed Surveyor the mechanical room with the two boilers for the 500 - 800 hallways. Boiler 1 displayed a digital tank temperature of 136 F and a set point (The temperature of the thermostat in order to maintain the desired temperature) of 149 F. Boiler 2 displayed a digital tank temperature of 135 F and a set point of 150 F. The thermometer past the hot water regulator for resident rooms displayed 136 F. The Maintenance Director stated that they have had some issues with the 500 - 800 boilers, which is why their set points are high. The Maintenance Director stated that the amount of hot water that is pushed into the system is controlled by an adjustable regulator past the boilers. The Maintenance Director stated that when they do their water temperature test in the rooms they do so with a digital thermometer and leave it under the water until the temperatures stops increasing. room [ROOM NUMBER] sink hot water was tested and displayed 137.0 F, which was verified with Surveyor's thermometer that displayed 137.4. room [ROOM NUMBER] sink hot water was tested and displayed 136.0 F. room [ROOM NUMBER] sink hot water was tested and displayed 137.8 F. room [ROOM NUMBER] sink hot water was tested and displayed 130.8 F. The Maintenance Director stated that he was going immediately to adjust the regulator for the 500 - 800 hallways to lower the temperatures and would continue to monitor. In an interview on 02/21/2024 at 11:37 AM, the Administrator stated that they wanted water temperatures to be between 106 F and 109 F. The Administrator stated that elevated water temperatures could result in a resident's skin being burned. At 12:00 PM, the ADMINISTRATOR stated that to her knowledge no resident had been burned by hot water during her time in the facility but told Surveyor to speak with the ADON who has worked in the facility longer. In an interview on 02/21/2024 at 12:04 PM, the ADON stated that elevated water temperatures in resident rooms could result in skin burns. The ADON stated that she had been with the facility for over three years and that no resident during that time had sustained a skin burn due to hot water. Observation on 02/21/2024 at 4:49 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.1 F down from 137.3 at 9:50 AM. Observation on 02/21/2024 at 4:55 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 124.7 F down from 137.0 F at 10:32 AM. Observation on 02/22/2024 at 9:37 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be at 108.3 F and the shower head at 107.2 F. Interview and Observation on 02/22/2024 at 9:55 AM, the Maintenance Director stated that the facility boilers were now being adjusted via the tank settings and not by way of the regulator. Hallway 500 - 800 tank 1 now displayed a temperature of 115 F and a set point of 123 F. Hallway 500 - 800 tank 2 now displayed a temperature of 119 F and a set point of 125 F. The temperature after the regulator now displayed 110 F. Observation on 02/22/2024 at 5:42 PM, the hot water was checked in the 600-hallway shower room at the shower head and displayed a temperature of 100.6 F. Observation on 02/22/2024 at 5:49 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to now be at 116.6 down from 145.0 F on 02/21/2024 at 8:43 AM. Observation on 02/22/2024 at 7:01 PM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to now be at 110.5 F and 94.6 F at the shower head. Review of facility water temperature log indicated the following recorded dates and room hot water temperatures in Fahrenheit. February 13, 2024, Rooms 712 at 110, 710 at 112, 708 at 113, and 604 at 112. February 16, 2024, Rooms 604 at 109, 602 at 104, and 712 -at 110, February 16, 2024, Rooms 713 at 110 Review of facility's Maintenance Manual for 2024, dated November 2023 revealed, Maintenance Checklist, Daily Tasks 4. Test water temperatures on a different resident room each day and update log. TEST WATER TEMPERATURE: Test (4) different rooms each day, Ensure patient room water temperatures are between 100 to 110 degrees Fahrenheit, Check resident rooms at the end of each wing on a rotating basis, Let the water run for a least three minutes before taking your reading. Record Results in the Water Temperature Log: Note any discrepancies, Adjust water heater settings as required, Retest as necessary. Review of the facility's Grievance log did not reveal any complaints of water temperature being too hot. Review of facility's incident and accidents did not reveal any injuries to residents due to hot water. Review of the current undated American Burn Association Scald Injury Prevention Educator's Guide provided the following information: .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further review of the Guide revealed that 100-degree F water was a safe temperature for bathing. Water at 120 degrees F would cause a third-degree burn (full thickness burn) in 5 minutes and 124 degrees F water would cause a third-degree burn in 3 minutes. The Guide further documented that water at 127 degrees F caused third degree burns in 1 minute, 133 degrees F in 15 seconds, and 140 degrees F in 5 seconds. The Administrator was notified of the Immediate Jeopardy on 03/12/2024 at 11:51 AM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was approved as follows: SURVEY TYPE: Annual Survey SURVEY DATE: 3/12/2024. Plan for REMOVAL Plan to remove immediate jeopardy. The facility failed to ensure residents had safe water temperatures in their bathroom sinks and shower rooms. F689 On 3/12/2024 the Administrator and Assistant Director of Nursing notified the Medical Director of immediate jeopardy. On 3/12/2024 Maintenance Director/Designee checked all residents' bathroom sinks, shower rooms, and all resident accessible water sources in the facility to make sure water temperatures were below 110.1F. On 3/12/2024 Regional Nurse Consultant/Designee checked all residents for any skin burns and document in EHR under progress notes for each resident. No residents were identified who had any skin burns. The Medical Director was updated on the assessments. COO (Chief Operating Officer) completed 1:1 in-service with Administrator on Water Temperature policy and Regional Nurse consultant completed 1:1 in-service with Assistants Director of Nursing on Water temperature policy, reporting any concerns or complaints, including water temperatures to Administrator upon discovery, and on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition on 3/12/2024. On 3/12/2024 Administrator completed in-services with Maintenance Director and IDT (Interdisciplinary team) water temperatures in residents' rooms, showers, and all resident accessible water sources to be below 110.1 and checking water temperatures daily. On 3/12/2024 Assistant Director of Nursing/Designee in-service staff on reporting any concerns or complaints regarding water temperatures to Maintenance Director or Administrator upon discovery. Direct Care staff will be in-serviced by ADON/Designee on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition. All staff, including the Agency, newly hired staff, and PRN will receive in-service and will not be allowed to start work until completed regarding reporting complaints and concerns from residents . The administrator will ensure all staff have completed in-services and training prior to starting work. The training will be completed by 3/12/2024. Ad-Hoc QAPI meeting was held on 3/12/2024, with the Medical Director, NHA (Nursing Home Administrator), Regional Nurse Consultant, Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 3/12/2024, Maintenance Director/Designee will check all residents' rooms and shower rooms in the facility water temperatures daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. The Administrator/designee will monitor compliance by completing an audit of five (5) residents' rooms/shower rooms per week for four (4) weeks to make sure water temperatures stay below 110.1F. This will be initiated on 3/12/2024. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 3/12/2024. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. The Plan of Removal was monitored from 03/12/2024-03/13/2024 and is as follows: In observations on 03/13/2024 Water Temperatures in Resident Rooms were as follows: 1:57 pm room [ROOM NUMBER] - 85 degrees 2:00 pm room [ROOM NUMBER] - 92 degrees 2:04 pm room [ROOM NUMBER] - 100 degrees 2:10 pm room [ROOM NUMBER] - 92 degrees 2:13 pm room [ROOM NUMBER] - 100 degrees 2:16 pm room - 601 - 102 degrees 2:20 pm room [ROOM NUMBER] - 103 degrees 2:24 pm room [ROOM NUMBER] - 102 degrees 2:28 pm The boiler temperatures for hallways 5 - 8 was 104 degrees. 2:32 pm The boiler temperatures for hallways 1 - 4 was 109 degrees. In an interview on 3-13-24 at 3:01 PM the ADM stated she was in-serviced by the COO about water temperatures. The temperature should not exceed 110.1 degrees. The risk factor if it does exceed this temperature is potential burns. This population is more at risk because elderly have thinner skin. Residents might not understand how to adjust the temperature settings, they might have a diagnosis that makes them more susceptible to getting burned. Residents might have nerve issues and they might not feel the burn and residents are slower in movement. They reviewed protocols that staff need to notify maintenance if residents have complaints that water is too hot or staff feel water is too hot. On 3-13-24 at 3:12 pm the Regional Nurse Consultant was in-serviced by COO. They reviewed the policy about the water temperatures. The water temperatures should be below 110. If staff feels temperatures were too high the resident should be assessed by a nurse and the nurse would tell the ADM and maintenance. CNAs can also tell ADM and maintenance but if CNAs are concerned about skin damage, they need to inform a nurse. She in-serviced the ADONs about water temperatures, burns and change in condition. In an interview on 03/13/24 at 11:59 am the Maintenance Manager said he went into all resident rooms and checked the water temperatures and confirmed that they were at temperatures of 110.1 and below. In an interview on 3-13-24 at 12:20 pm the SW was in-serviced on water temperatures. If the water is too high, over 110, she lets the maintenance director know. Hot water can harm elderly residents' skin because it is much more sensitive. The water can burn their hands. Their hands are more sensitive to the heat and could cause blisters. In an interview on 3-13-24 at 12:37 pm the ADON stated he was in-serviced recently by the corporate office and learned the temperatures should be between 100and not over 110 and thermostats should not be set higher than 110. If someone complains that water was hot to notify maintenance so water temperature can be checked. If a resident has redness or blistering they need to notify MD. It is important to have temperatures regulated to prevent burns. Because of residents' age group, their skin is more sensitive and need temperatures to be regulated. In an interview on 3-13-24 at 12:44 pm LVN P was in-serviced recently that discussed proper water temperatures. Water temperatures should be between 100 and 110 to prevent burns. The skin of the elderly is very fragile, and they can blister easily. In an interview on 3-13-24 at 12:49 pm Housekeeper R stated he was in-serviced about hot water and the need to report if a resident was burned. He should report to maintenance immediately if someone is burned because water temperature might be too high. Water temperatures in resident rooms should not be higher than 110. He has to be more particular about water temperature with the elderly because they have sensitive skin. In an interview on 3-13-24 at 1:01 pm CNA Q stated she was in-served about water temperature. The water should be 110 or lower. If she notices that resident has a blister or hot water burn, she should notify the nurse. If she notices that water temperature is too high, notify ADM and maintenance. Check water before residents come into contact with the water because they have sensitive skin like a baby. Sometimes residents react more slowly and that is a risk factor to being burned with hot water. In an interview on 3-13-24 at 1:05 PM CNA S stated she was in-serviced about water temperature. She said water should not be higher then 110, and should be 101 to 110 for residents. If the water was too hot they would have red spots on their body because they are more sensitive and if they see something like that, tell the nurse on duty. Residents are more susceptible to being burned because they get burned easier than younger people. In an interview on 3-13-24 at 1:29 pm LVN T stated she was in-serviced about the water temperatures in the facility. When they test the water temperature prior to resident going to shower, if it is too hot, notify management and maintenance. The temperature should not be above 110. This is important for the elderly because their skin is thinner and more fragile. In an interview on 3-13-24 at 1:13 PM CNA U stated she attended an in-service about hot water and if the resident gets burned. They discussed that the water temperature should be not over 110. If temperatures are over 110 the residents can get burns and blisters and sores. The skin of the elderly is softer and more tender so it is important that water temperature is not over 110. In an interview on 3-13-24 at 1:19 PM CNA E stated she was in-serviced about the water temperature. The water temperature should not be higher than 110 and if a resident gets scorched, report to the nurse. If she thinks the temperature is higher than 110 report to maintenance and the ADM. Residents' skin is not as tough as hers and residents' skin burns more easily. In an interview on 3-13-24 at 1:33 PM LVN W stated she was in-serviced about the temperature of water. When the resident complains about the temperature report immediately. The temperature of water should not be higher than 110. If she thinks the water is hotter tell the administrator and the maintenance person. The skin of the elderly was very thin and they can burn easily. In an interview on 3-13-24 at 1:37 pm LVN W -she was in-serviced recently. She said the water temperature should be 110 or below. If the water is too hot do not give resident a bath and notify maintenance. Because the residents are older, the hot water can burn their skin because their skin is thin. In an interview on 03/13/2024 at 3:26 pm the Resident in room [ROOM NUMBER] (where water temperature was too high), he said he did not receive any burns or injury from the water being too high. He said he knew how to adjust the water. In an interview on 3-13-24 at 3:33 pm COO stated she started the in-services and interviewed the regional nurse consultant and the AD. In the in-service she reviewed water temperature safety. They discussed that water temperatures can't be over 110. They discuss that the elderly have skin that is thinner and high water temperatures can harm the elderly. The elderly might have communication issues and not be able to communicate if the water is too hot. It is important to do skin checks if a resident is exposed to high water temperatures. They discussed how exposure to warm or hot water can affect the residents in the facility and how cognition and movement are involved when residents water temperature is too high. Reviewed the following inservices: 1. 1:1 in-service with Administrator on Water Temperature policy and Regional Nurse consultant 2. 1:1 in-service with Assistants Director of Nursing on Water temperature policy, reporting any concerns or complaints, including water temperatures to Administrator upon discovery, and on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition 3. Administrator in-services with Maintenance Director and IDT (Interdisciplinary team) water temperatures in residents' rooms, showers, and all resident accessible water sources to be below 110.1 and checking water temperatures daily 4. Assistant Director of Nursing/Designee in-services to staff on reporting any concerns or complaints regarding water temperatures to Maintenance Director or Administrator upon discovery. 5. Direct Care staff in-services by ADON/Designee on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition. 6. RNC in-service to ADONs on water temperature policy, reporting concerns or complaints including water temperatures to Administrator upon discovery, and on risk factors for scalding/burns in the elderly, signs and symptoms of burns, and changes in condition While the IJ was removed on 03/13/2024 the facility remained out of compliance at a severity level of no actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness.

Based on observations, interviews, and record reviews, the facility failed to ensure residents had the right to be free from neglect for 1 (Resident #1) of 13 residents reviewed for neglect in that: The facility failed to provide goods and services to Resident #1 that are necessary to ensuring Resident #1's bed wheels were locked on 10/16/23. Resident #1, who the facility knew was legally blind, rolled out of bed and fell on the ground. Resident #1 was transported by emergency medical services to the hospital on 10/26/23. Hospital x-rays revealed Resident #1 had a intertrochanteric fracture of right femur. An IJ was identified on 11/10/23. The IJ template was provided to the facility on [DATE] at 7:38 p.m. While the IJ was removed on 11/11/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of pain, injury, hospitalization , and a diminished quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right femur (hip), need for assistance with personal care, vascular dementia (a condition caused by a lack of blood flow and deprivation of oxygen to parts of the brain) without behavioral, psychotic, or mood disturbances, history of anxiety, age-related osteoporosis (a condition in which bones become weak and brittle), pain in unspecified hip, difficulty in walking, repeated falls, other lack of coordination, generalized muscle weakness, other abnormalities of gait and mobility, weakness, unsteadiness on feet, unspecified visual loss, and legal blindness. Review of Resident #1's quarterly MDS, revised on 09/19/23, reflected a BIMS score of 7, indicating a severely impaired cognition, he required limited assistance of one person with bed mobility and transfers, and he had no falls since admission. Review of Resident #1's quarterly care plan, revised on 09/13/23, reflected he was at risk for falls due to being legally blind. There were no interventions related to keeping the bed brakes locked or bed rails. There was an intervention of increased staff supervision with intensity based on Resident #1's need. Review of Resident #1's progress notes, dated 10/16/23 at 10:29 a.m. and documented by LVN A, reflected the following: This nurse heard some yelling while receiving report. The nurse that I was receiving report from checked on it and said everything was fine. After I finished receiving report, I heard a yelling from the same area. I checked on it and noted Resident #1 laying down beside his bed on the floor. Resident #1 had 2 pillows under his head and his knees were bent. CNA and myself assisted Resident #1 back into his bed and placed his pillows under his head again. When I asked Resident #1 what happened, he stated he rolled out of the bed due to the bed moving. I locked the bed in place. Resident #1 complained of pain in the right hip and stated, I think i bruised my pelvic bone. Vitals signs were normal. Resident #1 stated he had a 4 out of 10 for pain in the hip. There was some redness on the skin around the right hip area. This nurse notified ADON of the situation. The NP asked Resident #1 if he wanted to go to the hospital. He denied. This nurse received order for X-ray of Resident #1's right hip. Neuro initiated. 72 hour monitoring initiated. Attempted to contact RP but there is no RP on file. Review of Resident #1's progress notes, dated 10/16/23 at 10:48 a.m. and documented by Charge Nurse, reflected the following: X-ray tech in facility to x-ray Resident #1. Right hip, awaiting results. Review of Resident #1's progress notes, dated 10/16/23 at 1:17 p.m. and documented by ADON, reflected the following: Resident #1's right hip x-ray returned within normal limits. Resident #1 notified. Review of Resident #1's progress notes, from 10/17/23 through 10/18/23 and documented by LVN B, reflected there were no other fall incidents. There were also no progress notes from 10/18/23 through 10/25/23. Review of Resident #1's progress notes, dated 10/26/23 at 5:02 a.m. and documented by NP, reflected the following: Received a call from nursing that Resident #1 is complaining of left leg/hip pain. Resident #1 is own RP and is telling nursing that he demands to go to the hospital and if they will not send him, he will call transport and send himself. Resident #1 had been receiving Tylenol on a regular basis but continues to have pain. Review of Resident #1's progress notes, dated 10/26/23 at 7:16 a.m. and documented by LVN C, reflected the following: Resident #1 reported that he was in excruciating pain in left leg and was unable to extend leg. Stated that he wanted to go to hospital. NP did offer X-ray and Resident #1 declined said he wanted to go to ER. I did notify and spoke with NP who was familiar with Resident #1 and did video call. I did mention to NP that Resident #1 was given acetaminophen 650mg and was not effective. No noted swelling or redness noted to left leg when checked. EMS notified. Resident #1 did depart with transport at 5:20 a.m. Resident #1 is his own RP. Face sheet, MDS, and out of hospital DNR given to EMS. DON made aware at end of shift. Review of Resident #1's post-fall observation report, dated 10/16/23 at 4:37 p.m. and documented on 10/27/23 at 4:41 p.m. by ADON, reflected Resident #1 had an unwitnessed fall in his room. Per the nurse's report, Resident #1 stated his bed shifted and he rolled out of the bed onto the floor. Resident #1 was in bed, alert, and oriented prior to the fall. Resident #1's ambulatory status was unable to ambulate. Resident #1 wore yellow non-skid socks at time of fall. Resident #1 took nine or more medications and received antihypertensives (a class of drugs used to prevent high blood pressure complications). Resident #1 had no falls in the last 90 days. Resident #1's bed was not locked was listed as a potential factor that could have contributed to the fall. Review of Resident #1's provider investigation report documented by ADM on 10/26/23 reflected the incident date/time was unknown and the date reported to State Agency was on 10/26/23 at 12:55 p.m. Resident #1 required extensive assistance with functional ability, having a BIMS score of 7, legal blindness, weakness, pain, lack of coordination, interviewable, not independently ambulatory, and had capacity to make informed decisions. There were no witnesses to Resident #1's incident. On 10/26/23 at approximately 5:00 p.m., Resident #1 told the nurse he was in excruciating pain in his left leg, he was assessed, was unable to extend his leg, had no redness or swelling, given pain medication, was offered a mobile x-ray, declined the offer, insisted on going to the hospital, was transported to the hospital, x-rayed, and had a right hip fracture . On 10/16/23, Resident #1 rolled out of bed, at the time complained of right hip pain, mobile x-ray came out to the facility, and the results were negative. Investigation findings were inconclusive. Review of Resident #1's portable x-ray report, dated 10/16/23, there was no evidence of acute fracture to his right hip and pelvis. Review of Resident #1's hospital records, dated 10/26/23, reflected Resident #1 had comminuted intertrochanteric fracture of right femur. Resident #1 told hospital staff that he sustained the injury after a ground level fall a week ago when trying to get out of bed. Resident #1 also told hospital staff he had immediate hip pain after his fall and x-rays were taken at the facility, but no fracture was identified. Resident #1 told hospital staff that his hip continued to hurt so he was taken to the hospital on 10/26/23, where further x-rays were performed, and intertrochanteric fracture of right femur was discovered. Resident #1 was a household ambulator (a person who required assistance entering and exiting structures and had difficulty climbing stairs in the home) with a blind stick, but he told hospital staff he had been mostly in bed for the past six months. Review of Resident #1's active orders on 11/10/23 reflected there were no orders related to ensuring Resident #1's bed was locked and bed rails. Review of Resident #1's MAR from 10/01/23 through 10/31/23 reflected his pain level was 0/10 from 10/16/23 through 10/17/23, 3/10 on 10/18/23, and 0/10 from 10/19/23 through 10/25/23. Resident #1's pain levels were not recorded on 10/26/23 due to him going to the hospital. Resident #1 was given one methocarbamol 500 mg tablet twice a day, which was provided on 10/25/23 and 10/26/23 . Resident #1 was monitored for bruising, change in mental status/condition, pain, or other injuries related to fall every shift from 10/16/23 through 10/19/23. During an interview on 11/10/23 at 11:04 a.m., Charge Nurse stated she was trained and often in-serviced on neglect and falls by the DON and ADON. Charge Nurse also stated she was recently in-serviced on the topics at the beginning of this week and last week. Charge Nurse stated the ADM was the abuse and neglect coordinator. Charge Nurse also stated she never had to report and was comfortable reporting neglect. Charge Nurse stated she worked with Resident #1 in the past. Charge Nurse also stated Resident #1 never fell at the facility during the time she worked with him. Charge Nurse stated if a resident was on the ground, she was trained to assess the resident, check the resident's vitals, obtain help from another staff member, put the resident back in bed if safe to do so, and contact EMS if she suspected the resident sustained a fracture. Charge Nurse also stated residents were checked on every two hours by CNAs and LVNs. During an observation and interview on 11/10/23 beginning at 1:09 p.m., Resident #1 was lying on his back in his bed. Resident #1 was clean, comfortable, and had his call light next to him. Resident #1 had bed bars installed on his bed near the headboard and the bed wheels were locked. Resident #1 had a purple-colored bruise on his right forearm. Resident #1 stated he slipped, fell out of bed, and broke his hip three weeks ago. Resident #1 stated the bed was moving when he was trying to reposition himself in bed. Resident #1 stated he did not know his bed was not locked, why his bed was not locked, and when and who unlocked his bed. Resident #1 stated he was legally blind. Resident #1 stated on the day of his fall incident, he yelled for help when he was on the ground. Resident #1 stated staff x-rayed him at the facility and he had no fractures. Resident #1 stated a week and a half later, he felt more pain, was sent to hospital, x-rayed, and had a fracture. Resident #1 stated he never fell at the facility or had any other incidents between 10/16/23 and 10/26/23. Resident #1 stated he was on the floor for an hour and a half until staff came in his room to help him. Resident #1 stated he had no bed rails on his bed on the day he rolled out of bed and fell on the ground. Resident #1 stated he never fell out of bed in the past prior to the fall incident. Resident #1 stated staff did not check on him and he could only get staff to come check on him when he pressed his call light for assistance. Resident #1 stated staff took 3 hours to answer his call light. Resident #1 stated he did not file a grievance about staffing because the SW was not available and did not know what she was doing. During an interview on 11/10/23 at 2:25 p.m., DON stated she was trained on abuse, neglect, and falls. DON also stated the ADM was the abuse and neglect coordinator. DON stated she trained staff to notify a nurse, make sure the resident was safe, a nurse would assess the resident's condition if a resident was on the ground. DON also stated if the resident expressed pain, she trained staff to notify the resident's MD and request an x-ray. DON stated if staff suspected the resident sustained a fracture, she trained them to send the resident to the hospital to be x-rayed and further evaluated. DON also stated she trained staff to administer pain medication and/or treatment to the resident if they are able to do such, conduct neurological checks on the resident, and notify the resident's RP of the fall. DON stated CNAs and LVNs checked on residents every hour or more. DON also stated any staff member could check on a resident. DON stated she was notified by a nurse that Resident #1 was on the floor on 10/16/23. DON also stated Resident #1 expressed he was experiencing pain in his right hip and staff wanted to send him out, but he refused to go to the hospital. DON stated staff ordered a mobile x-ray for Resident #1, in which his x-ray results were negative for fracture on 10/16/23. DON also stated on 10/26/23, Resident #1 expressed he was experiencing pain in his left side and staff sent him out based on his telehealth visit with the NP. DON stated the hospital ordered an x-ray Resident #1, in which his x-ray results were positive for a right hip fracture . DON also stated she did not know if Resident #1 expressed experiencing pain between 10/17/23 and 10/25/23. DON stated she could not recall if Resident #1 had any other falls prior to 10/16/23. DON also stated she never received complaints about residents left on floor after a fall. During an interview on 11/10/23 at 3:45 p.m., DON stated staff unlocked residents' beds whenever they performed incontinent care or moved the bed to get something that fell underneath it. DON also stated she could not remember if Resident #1 had a mobility bar installed on his bed prior to 10/16/23. DON stated LVN A was supposed to work on 11/07/23, but he did not show up for work. DON stated she made multiple attempts to contact LVN A, but he did not return any of her calls or text messages. During an interview on 11/10/23 at 4:21 p.m., DON stated she and the ADONs verbalized to all staff about locking residents' beds following Resident #1's incident on 10/16/23. DON also stated she did not document her and the ADONs verbalizing to all staff about locking residents' beds. DON stated the CNAs, LVNs, MAs trained each other on how to lock and unlock residents' beds. DON also stated management staff did not train nursing staff how and when to unlock and lock residents' beds. DON stated there were no staff designated to oversee and ensure residents' beds were locked. DON also stated the facility did not have a policy and procedure on locking and unlocking residents' beds. DON stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 4:53 p.m., ADM stated there was no training given to staff that specifically highlighted how and when to lock and unlock residents' beds. ADM also stated Resident #1's incident was used as an example and scenario during the fall prevention and intervention, abuse, and neglect in-services given to staff. ADM stated housekeeping staff unlocked and locked residents' beds when they cleaned residents' rooms. ADM also stated CNAs and LVNs unlocked and locked residents' beds when transferring residents with a Hoyer lift. ADM stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 5:41 p.m., MS stated he was not sure if he ever had a service order to check or repair a resident's bed because it did not lock. MS also stated housekeeping staff sometimes moved residents' beds when they cleaned residents' rooms. MS stated he believed he repaired Resident #1's bed remote control that raised and lowered his bed. MS also stated he never had to replace a lock or residents' bed because it did not unlock and lock. An attempt to interview LVN A was made on 11/10/23 at 5:54 p.m., but LVN A did not return the surveyor's call prior to exit. During an interview on 11/10/23 at 6:05 p.m., Charge Nurse stated she did not know what happened on 10/16/23. Charge Nurse also stated she heard about Resident #1's unwitnessed fall after other staff responded to it on 10/16/23. Charge Nurse stated there was an LVN who checked on Resident #1 before LVN A, but she did not know who it was. Charge Nurse also stated LVNs, and CNAs unlocked and locked residents' beds when transferring a resident using a Hoyer lift . Charge Nurse stated housekeeping unlocked and locked residents' beds when they cleaned residents' rooms. During an interview on 11/10/23 at 6:37 p.m., CNA C stated she was trained and in-serviced on abuse, neglect, and falls and was recently in-serviced on the topics last week. CNA C also stated the ADM was the abuse and neglect coordinator. CNA C stated she was comfortable reporting abuse and neglect. CNA C also stated she never had to unlock and move a resident's bed. CNA C stated she knew how to unlock and lock resident's bed. CNA C also stated she was not trained by management staff on how to unlock and lock residents' beds. CNA C stated she was trained by another CNA on how to unlock and lock residents' beds. CNA C also stated she never observed housekeeping staff unlock and move residents' beds. Review of the facility's incident log from 10/1/23 through 11/10/23 reflected Resident #1 had an unwitnessed fall in his room on 10/16/23 at 6:10 a.m. Review of the facility's maintenance log from October 2023 through November 2023 reflected MS replaced Resident #1's missing bed remote on 10/31/23. There were no other service orders related to Resident #1's bed. Review of facility's in-services reflected staff were trained on one-to-one observation on, abuse, neglect, falls, redirecting agitated residents and call lights on 10/25/23 and 10/26/23 and diffusing aggressive behaviors, abuse, and neglect on 10/04/23. Review of the facility falls and fall risk managing policy and procedure revised in December 2007 reflected the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's analyzing occurrences of abuse, neglect, mistreatment and theft/misappropriation of resident property policy and procedure revised in November 2010 reflected the following: Policy Statement: All occurrences of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property will be analyzed by the Quality Assessment and Assurance Committee to determine if system changes need to be made. Policy Interpretation and Implementation 1. The Quality Assessment and Assurance Committee will review all reports of abuse, neglect, mistreatment, injuries of unknown source, and theft or misappropriation of resident property during their regularly scheduled meetings. 2. Reviews of each occurrence will be made to determine if policies, procedures, or facility systems need to be modified to prevent further incidents of abuse or theft. 3. The QAA committee will determine through a coordinated effort: a. If a thorough investigation is conducted. b. Whether the resident is protected. c. Whether an analysis was conducted as to why the situation occurred. d. Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors); and e. Whether there is further need for systemic action such as: i. Insight on needed revision to the policies and procedures that prohibit and prevent abuse/neglect/misappropriation/exploitation ii. Increased training on specific components of identifying and reporting that staff may not be aware of or are confused about, iii. Efforts to educate residents and their families about how to report any alleged violations without fear of repercussions, iv. Measures to verify the implementation of corrective actions and timeframes, and v. Tracking patterns of similar occurrences. 4. The Quality Assessment and Assurance Committee will provide the Administrator with a written report of its findings and recommendations. The Administrator will review such recommendations and act accordingly. 5. Copies of any changes to our abuse prevention program policies and procedures will be provided to residents and facility staff as established by facility policy and training programs. Review of the facility's preventing resident abuse policy and procedure revised in November 2010 reflected the following: Policy Statement: Our facility will not condone any form of resident abuse and will continually monitor our facility's policies, procedures, training programs, systems, etc., to assist in preventing resident abuse. Policy Interpretation and Implementation: a. Our facility's goal is to achieve and maintain an abuse-free environment. b. Our abuse prevention/intervention program includes, but is not necessarily limited to, the following: c. Training all staff and practitioners how to resolve conflicts appropriately. f. The facility will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur. h. Involving the resident/family group council in developing, monitoring, and evaluating the facility's abuse prevention program. m. Assessing, care planning, and monitoring residents with needs and behaviors that may lead to conflict or neglect. r. Identifying areas within the facility that may make abuse and/or neglect more likely to occur and monitoring these areas regularly. Review of the facility's abuse prevention program policy and procedure revised November 2010 reflected the following: Policy Statement: Our residents have the right to be free from abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources, and misapprop1iation of resident property, corporal punishment, and involuntary seclusion. Policy Interpretation and Implementation: 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of our residents. Our abuse prevention program provides policies and procedures that govern, as a minimum: a. Establishing a safe environment. b. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and/or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. d. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. a. Addressing features of the physical environment that may make abuse, neglect, exploitation, and misappropriation of resident property more likely to occur; and b. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. d. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophic reactions, etc. j. An ongoing review and analysis of abuse incidents/Coordination with QAPI; and k. The implementation of changes to prevent future occurrences of abuse. Review of the facility's recognizing signs and symptoms of abuse/neglect policy and procedure revised in April 2012 reflected the following: Policy Statement: Our facility will not condone any form of resident abuse or neglect. To aid in abuse prevention, all personnel are to report any signs or symptoms of abuse/neglect to their supervisor or to the Director of Nursing Services immediately. Policy Interpretation and Implementation: 2. Neglect is defined as failure to provide goods and services a necessary to avoid physical harm, mental anguish, or mental illness. 3. The following are some examples of actual abuse/neglect and signs and symptoms of abuse/neglect that should be promptly reported. However, this listing is not all-inclusive. Other signs and symptoms or actual abuse/neglect may be apparent. When it doubt, report it. Signs of/Actual Physical Neglect: Inadequate provision of care. Leaving someone unattended who needs supervision. Possible signs/symptoms of psychological abuse/neglect: Anger. Review of the facility's bed safety policy and procedure revised in December 2007 reflected the following: Policy: Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), The facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position.). c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications. d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard, and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 3. The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 10. When using side rails for any reason, the staff shall take measures to reduce related risks. 11. Side rails shall not be used as protective restraints. Should a protective restraint be used. our facility's protocol for the use of restraints shall be followed. 12. The use of physical restraint on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals. 13. The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pe1tinent laws and regulations including the Safe Medical Devices Act. This failure resulted in the identification of an IJ on 11/10/23 at 3:51 p.m. The ADM was notified and provided with the IJ template on 11/10/23 at 7:38 p.m. The following Plan of Removal was submitted by the facility and accepted on 11/11/23 at 1:36 p.m.: Plan to remove immediate jeopardy. The facility failed to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility failed to lock R1's bed. All residents residing in the facility can be affected by this deficiency. On 11/10/2023 the Administrator and Director of Nursing notified the Medical Director of immediate jeopardy. On 11/10/2023 Maintenance Director/Designee checked all the occupied beds in the facility to make sure they were locked. On 11/10/2023 Director of Nursing/Designee checked all residents that are currently in the facility for safety while in bed, including making sure all beds are locked. No other residents were identified who had injuries due to unlocked beds while occupying the bed. Medical Director was updated of the assessments. On 11/10/2023 Administrator/Designee completed in-services with nursing staff and housekeeping on how to lock and unlock patients' beds and abuse and neglect prevention. All staff, including Agency, new hire staff, and PRN will be in-service and will not be allowed to start work till done so. Administrator will ensure all staff completed in-services and training prior to start working. The training will be completed by 11/10/2023. Ad-Hoc QAPI meeting was held on 11/10/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 11/10/2023, Maintenance Director/Designee will check all beds in the facility to be locked while in use or if patient is occupying the bed daily [TRUNCA

Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained free of accidents and hazards and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 11 residents reviewed for falls in that: 1. The facility failed to ensure Resident #1's bed wheels were locked on 10/16/23. Resident #1, who was legally blind, rolled out of bed and fell on the ground. Resident #1 was transported by emergency medical services to the hospital on 10/26/23. Hospital x-rays revealed Resident #1 had a intertrochanteric fracture of right femur. 2. The facility failed to investigate and determine who unlocked Resident #1's bed. 3. The facility failed to train staff on how and when to unlock and lock residents' beds. 4. The facility failed to maintain a policy and procedure for how and when to unlock and lock residents' beds. 5. The facility failed to provide oversight to ensure staff were locking residents' beds. An IJ was identified on 11/10/23. The IJ template was provided to the facility on [DATE] at 7:38 p.m. While the IJ was removed on 11/11/23, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not immediate jeopardy because of the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of accidents, hazards, pain, injury, hospitalization , and a diminished quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including unspecified fracture of right femur (hip), need for assistance with personal care, vascular dementia (a condition caused by a lack of blood flow and deprivation of oxygen to parts of the brain) without behavioral, psychotic, or mood disturbances, history of anxiety, age-related osteoporosis (a condition in which bones become weak and brittle), pain in unspecified hip, difficulty in walking, repeated falls, other lack of coordination, generalized muscle weakness, other abnormalities of gait and mobility, weakness, unsteadiness on feet, unspecified visual loss, and legal blindness. Review of Resident #1's quarterly MDS, revised on 09/19/23, reflected a BIMS score of 7, indicating a severely impaired cognition, he required limited assistance of one person with bed mobility and transfers, and he had no falls since admission. Review of Resident #1's quarterly care plan, revised on 09/13/23, reflected he was at risk for falls due to being legally blind. There were no interventions related to keeping the bed brakes locked or bed rails. There was an intervention of increased staff supervision with intensity based on Resident #1's need. Review of Resident #1's progress notes, dated 10/16/23 at 10:29 a.m. and documented by LVN A, reflected the following: This nurse heard some yelling while receiving report. The nurse that I was receiving report from checked on it and said everything was fine. After I finished receiving report, I heard a yelling from the same area. I checked on it and noted Resident #1 laying down beside his bed on the floor. Resident #1 had 2 pillows under his head and his knees were bent. CNA and myself assisted Resident #1 back into his bed and placed his pillows under his head again. When I asked Resident #1 what happened, he stated he rolled out of the bed due to the bed moving. I locked the bed in place. Resident #1 complained of pain in the right hip and stated, I think i bruised my pelvic bone. Vitals signs were normal. Resident #1 stated he had a 4 out of 10 for pain in the hip. There was some redness on the skin around the right hip area. This nurse notified ADON of the situation. The NP asked Resident #1 if he wanted to go to the hospital. He denied. This nurse received order for X-ray of Resident #1's right hip. Neuro initiated. 72 hour monitoring initiated. Attempted to contact RP but there is no RP on file. Review of Resident #1's progress notes, dated 10/16/23 at 10:48 a.m. and documented by Charge Nurse, reflected the following: X-ray tech in facility to x-ray Resident #1. Right hip, awaiting results. Review of Resident #1's progress notes, dated 10/16/23 at 1:17 p.m. and documented by ADON, reflected the following: Resident #1's right hip x-ray returned within normal limits. Resident #1 notified. Review of Resident #1's progress notes, from 10/17/23 through 10/18/23 and documented by LVN B, reflected there were no other fall incidents. There were also no progress notes from 10/18/23 through 10/25/23. Review of Resident #1's progress notes, dated 10/26/23 at 5:02 a.m. and documented by NP, reflected the following: Received a call from nursing that Resident #1 is complaining of left leg/hip pain. Resident #1 is own RP and is telling nursing that he demands to go to the hospital and if they will not send him, he will call transport and send himself. Resident #1 had been receiving Tylenol on a regular basis but continues to have pain. Review of Resident #1's progress notes, dated 10/26/23 at 7:16 a.m. and documented by LVN C, reflected the following: Resident #1 reported that he was in excruciating pain in left leg and was unable to extend leg. Stated that he wanted to go to hospital. NP did offer X-ray and Resident #1 declined said he wanted to go to ER. I did notify and spoke with NP who was familiar with Resident #1 and did video call. I did mention to NP that Resident #1 was given acetaminophen 650mg and was not effective. No noted swelling or redness noted to left leg when checked. EMS notified. Resident #1 did depart with transport at 5:20 a.m. Resident #1 is his own RP. Face sheet, MDS, and out of hospital DNR given to EMS. DON made aware at end of shift. Review of Resident #1's post-fall observation report, dated 10/16/23 at 4:37 p.m. and documented on 10/27/23 at 4:41 p.m. by ADON, reflected Resident #1 had an unwitnessed fall in his room. Per the nurse's report, Resident #1 stated his bed shifted and he rolled out of the bed onto the floor. Resident #1 was in bed, alert, and oriented prior to the fall. Resident #1's ambulatory status was unable to ambulate. Resident #1 wore yellow non-skid socks at time of fall. Resident #1 took nine or more medications and received antihypertensives (a class of drugs used to prevent high blood pressure complications). Resident #1 had no falls in the last 90 days. Resident #1's bed was not locked was listed as a potential factor that could have contributed to the fall. Review of Resident #1's provider investigation report documented by ADM on 10/26/23 reflected the incident date/time was unknown and the date reported to State Agency was on 10/26/23 at 12:55 p.m. Resident #1 required extensive assistance with functional ability, having a BIMS score of 7, legal blindness, weakness, pain, lack of coordination, interviewable, not independently ambulatory, and had capacity to make informed decisions. There were no witnesses to Resident #1's incident. On 10/26/23 at approximately 5:00 p.m., Resident #1 told the nurse he was in excruciating pain in his left leg, was assessed, was unable to extend his leg, had no redness or swelling, given pain medication, was offered a mobile x-ray, declined the offer, insisted on going to the hospital, was transported to the hospital, x-rayed, and had a right hip fracture . On 10/16/23, Resident #1 rolled out of bed, at the time complained of right hip pain, mobile x-ray came out to the facility, and the results were negative. Investigation findings were inconclusive. Review of Resident #1's portable x-ray report, dated 10/16/23, there was no evidence of acute fracture to his right hip and pelvis. Review of Resident #1's hospital records, dated 10/26/23, reflected Resident #1 had a intertrochanteric fracture of right femur. Resident #1 told hospital staff that he sustained the injury after a ground level fall a week ago when trying to get out of bed. Resident #1 also told hospital staff he had immediate hip pain after his fall and x-rays were taken at the facility, but no fracture was identified. Resident #1 told hospital staff that his hip continued to hurt so he was taken to the hospital on 10/26/23, where further x-rays were performed, and the right femur fracture was discovered. Resident #1 was a household ambulator (a person who required assistance entering and exiting structures and had difficulty climbing stairs in the home) with a blind stick, but he told hospital staff he had been mostly in bed for the past six months. Review of Resident #1's active orders on 11/10/23 reflected there were no orders related to ensuring Resident #1's bed was locked and bed rails. Review of Resident #1's MAR from 10/01/23 through 10/31/23 reflected his pain level was 0/10 from 10/16/23 through 10/17/23, 3/10 on 10/18/23, and 0/10 from 10/19/23 through 10/25/23. Resident #1's pain levels were not recorded on 10/26/23 due to him going to the hospital. Resident #1 was given one methocarbamol 500 mg tablet twice a day, which was provided on 10/25/23 and 10/26/23 . Resident #1 was monitored for bruising, change in mental status/condition, pain, or other injuries related to fall every shift from 10/16/23 through 10/19/23. During an interview on 11/10/23 at 11:04 a.m., Charge Nurse stated she was trained and often in-serviced on neglect and falls by the DON and ADON. Charge Nurse also stated she was recently in-serviced on the topics at the beginning of this week and last week. Charge Nurse stated the ADM was the abuse and neglect coordinator. Charge Nurse also stated she never had to report and was comfortable reporting neglect. Charge Nurse stated she worked with Resident #1 in the past. Charge Nurse also stated Resident #1 never fell at the facility during the time she worked with him. Charge Nurse stated if a resident was on the ground, she was trained to assess the resident, check the resident's vitals, obtain help from another staff member, put the resident back in bed if safe to do so, and contact EMS if she suspected the resident sustained a fracture. Charge Nurse also stated residents were checked on every two hours by CNAs and LVNs. During an observation and interview on 11/10/23 beginning at 1:09 p.m., Resident #1 was lying on his back in his bed. Resident #1 was clean, comfortable, and had his call light next to him. Resident #1 had bed bars installed on his bed near the headboard and the bed wheels were locked. Resident #1 had a purple-colored bruise on his right forearm. Resident #1 stated he slipped, fell out of bed, and broke his hip three weeks ago. Resident #1 stated the bed was moving when he was trying to reposition himself in bed. Resident #1 stated he did not know his bed was not locked, why his bed was not locked, and when and who unlocked his bed. Resident #1 stated he was legally blind. Resident #1 stated on the day of his fall incident, he yelled for help when he was on the ground. Resident #1 stated staff x-rayed him at the facility and he had no fractures. Resident #1 stated a week and a half later, he felt more pain, was sent to hospital, x-rayed, and had a fracture. Resident #1 stated he never fell at the facility or had any other incidents between 10/16/23 and 10/26/23. Resident #1 stated he was on the floor for an hour and a half until staff came in his room to help him. Resident #1 stated he had no bed rails on his bed on the day he rolled out of bed and fell on the ground. Resident #1 stated he never fell out of bed in the past prior to the fall incident. Resident #1 stated staff did not check on him and he could only get staff to come check on him when he pressed his call light for assistance. Resident #1 stated staff took 3 hours to answer his call light. Resident #1 stated he did not file a grievance about staffing because the SW was not available and did not know what she was doing. During an interview on 11/10/23 at 2:25 p.m., DON stated she was trained on abuse, neglect, and falls. DON also stated the ADM was the abuse and neglect coordinator. DON stated she trained staff to notify a nurse, make sure the resident was safe, a nurse would assess the resident's condition if a resident was on the ground. DON also stated if the resident expressed pain, she trained staff to notify the resident's MD and request an x-ray. DON stated if staff suspected the resident sustained a fracture, she trained them to send the resident to the hospital to be x-rayed and further evaluated. DON also stated she trained staff to administer pain medication and/or treatment to the resident if they are able to do such, conduct neurological checks on the resident, and notify the resident's RP of the fall. DON stated CNAs and LVNs checked on residents every hour or more. DON also stated any staff member could check on a resident. DON stated she was notified by a nurse that Resident #1 was on the floor on 10/16/23. DON also stated Resident #1 expressed he was experiencing pain in his right hip and staff wanted to send him out, but he refused to go to the hospital. DON stated staff ordered a mobile x-ray for Resident #1, in which his x-ray results were negative for fracture on 10/16/23. DON also stated on 10/26/23, Resident #1 expressed he was experiencing pain in his left side and staff sent him out based on his telehealth visit with the NP. DON stated the hospital ordered an x-ray Resident #1, in which his x-ray results were positive for a right hip fracture . DON also stated she did not know if Resident #1 expressed experiencing pain between 10/17/23 and 10/25/23. DON stated she could not recall if Resident #1 had any other falls prior to 10/16/23. DON also stated she never received complaints about residents left on floor after a fall. During an interview on 11/10/23 at 3:45 p.m., DON stated staff unlocked residents' beds whenever they performed incontinent care or moved the bed to get something that fell underneath it. DON also stated she could not remember if Resident #1 had a mobility bar installed on his bed prior to 10/16/23. DON stated LVN A was supposed to work on 11/07/23, but he did not show up for work. DON stated she made multiple attempts to contact LVN A, but he did not return any of her calls or text messages. During an interview on 11/10/23 at 4:21 p.m., DON stated she and the ADONs verbalized to all staff about locking residents' beds following Resident #1's incident on 10/16/23. DON also stated she did not document her and the ADONs verbalizing to all staff about locking residents' beds. DON stated the CNAs, LVNs, MAs trained each other on how to lock and unlock residents' beds. DON also stated management staff did not train nursing staff how and when to unlock and lock residents' beds. DON stated there were no staff designated to oversee and ensure residents' beds were locked. DON also stated the facility did not have a policy and procedure on locking and unlocking residents' beds. DON stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 4:53 p.m., ADM stated there was no training given to staff that specifically highlighted how and when to lock and unlock residents' beds. ADM also stated Resident #1's incident was used as an example and scenario during the fall prevention and intervention, abuse, and neglect in-services given to staff. ADM stated housekeeping staff unlocked and locked residents' beds when they cleaned residents' rooms. ADM also stated CNAs and LVNs unlocked and locked residents' beds when transferring residents with a Hoyer lift. ADM stated she did not know why Resident #1's bed was unlocked and did not know who left his bed unlocked on 10/16/23. During an interview on 11/10/23 at 5:41 p.m. , MS stated he was not sure if he ever had a service order to check or repair a resident's bed because it did not lock. MS also stated housekeeping staff sometimes moved residents' beds when they cleaned residents' rooms. MS stated he believed he repaired Resident #1's bed remote control that raised and lowered his bed. MS also stated he never had to replace a lock or residents' bed because it did not unlock and lock. An attempt to interview LVN A was made on 11/10/23 at 5:54 p.m., but LVN A did not return the surveyor's call prior to exit. During an interview on 11/10/23 at 6:05 p.m., Charge Nurse stated she did not know what happened on 10/16/23. Charge Nurse also stated she heard about Resident #1's unwitnessed fall after other staff responded to it on 10/16/23. Charge Nurse stated there was an LVN who checked on Resident #1 before LVN A, but she did not know who it was. Charge Nurse also stated LVNs and CNAs unlocked and locked residents' beds when transferring a resident using a Hoyer lift. Charge Nurse stated housekeeping unlocked and locked residents' beds when they cleaned residents' rooms . During an interview on 11/10/23 at 6:37 p.m., CNA C stated she was trained and in-serviced on abuse, neglect, and falls and was recently in-serviced on the topics last week. CNA C also stated the ADM was the abuse and neglect coordinator. CNA C stated she was comfortable reporting abuse and neglect. CNA C also stated she never had to unlock and move a resident's bed. CNA C stated she knew how to unlock and lock resident's bed. CNA C also stated she was not trained by management staff on how to unlock and lock residents' beds. CNA C stated she was trained by another CNA on how to unlock and lock residents' beds. CNA C also stated she never observed housekeeping staff unlock and move residents' beds. Review of the facility's incident log from 10/1/23 through 11/10/23 reflected Resident #1 had an unwitnessed fall in his room on 10/16/23 at 6:10 a.m. Review of the facility's maintenance log from October 2023 through November 2023 reflected MS replaced Resident #1's missing bed remote on 10/31/23. There were no other service orders related to Resident #1's bed. Review of facility's in-services reflected staff were trained on one-to-one observation, abuse, neglect, falls, redirecting agitated residents and call lights on 10/25/23 and 10/26/23 and diffusing aggressive behaviors, abuse, and neglect on 10/04/23. Review of the facility falls and fall risk managing policy and procedure revised in December 2007 reflected the following: Policy Statement: Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Policy Interpretation and Implementation: Prioritizing Approaches to Managing Falls and Fall Risk 1. The staff, with the input of the Attending Physician, will identify appropriate interventions to reduce the risk of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions (i.e., to try one or a few at a time, rather than many at once). 2. Examples of initial approaches might include exercise and balance training or a rearrangement of room furniture. 6. In conjunction with the Attending Physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling. Monitoring Subsequent Falls and Fall Risk 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. The staff and/or physician will document the basis for conclusions that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the facility's accidents and incidents investigating and reporting policy and procedure revised in April 2013 reflected the following: Policy Statement: All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation: 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. 3. This facility is in compliance with current rules and regulations governing accidents and/or incidents involving a medical device. 5. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall complete a Report of Incident/Accident form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. 6. The Director of Nursing shall ensure that the Administrator receives a copy of the Report of Incident/Accident form for each occurrence. Review of the facility's bed safety policy and procedure revised in December 2007 reflected the following: Policy: Our facility shall strive to provide a safe sleeping environment for the resident. Policy Interpretation and Implementation: 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), The facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks. b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position.). c. Ensure that when bed system components are worn and need to be replaced, components meet manufacturer specifications. d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard, and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 3. The maintenance department shall provide a copy of inspections to the Administrator and report results to the QA Committee for appropriate action. Copies of the inspection results and QA Committee recommendations shall be maintained by the Administrator and/or Safety Committee. 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 10. When using side rails for any reason, the staff shall take measures to reduce related risks. 11. Side rails shall not be used as protective restraints. Should a protective restraint be used. our facility's protocol for the use of restraints shall be followed. 12. The use of physical restraint on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals. 13. The staff shall report to the Director of Nursing and Administrator any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Administrator shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pe1tinent laws and regulations including the Safe Medical Devices Act. This failure resulted in the identification of an IJ on 11/10/23 at 3:51 p.m. The ADM was notified and provided with the IJ template on 11/10/23 at 7:38 p.m. The following Plan of Removal was submitted by the facility and accepted on 11/11/23 at 1:36 p.m.: Plan to remove immediate jeopardy. The facility failed to lock Resident #l's bed. Resident #l rolled out of bed, fell on the ground, and fractured his right hip. All residents residing in the facility can be affected by this deficiency. On 11/10/2023 the Administrator and Director of Nursing notified the Medical Director of immediate jeopardy. On 11/10/2023 Maintenance Director/Designee checked all the occupied beds in the facility to make sure they were locked. On 11/10/2023 Director of Nursing/Designee checked all residents that are currently in the facility for safety while in bed, including making sure all beds are locked. No other residents were identified who had injuries due to unlocked beds while occupying the bed. Medical Director was updated of the assessments. On 11/10/2023 Administrator/Designee completed in-services with nursing staff and housekeeping on how to lock and unlock patients' beds. All staff, including Agency, new hire staff, and PRN will be in-service and will not be allowed to start work till done so. Administrator will ensure all staff completed in-services and training prior to start working. The training will be completed by 11/10/2023. Ad-Hoc QAPI meeting was held on 11/10/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 11/10/2023, Maintenance Director/Designee will check all beds in the facility to be locked while in use or if patient is occupying the bed daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The staff assigned to the resident will check the bed throughout their shift. If a bed is found unlocked, 1:1 in-service will be completed immediately with staff who are assigned to the resident and bed will be locked immediately. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. The Administrator/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks to make sure beds are locked while patients are in beds. This will be initiated on 11/10/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. The Administrator will be responsible for ensuring this plan is completed on 11/10/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. The survey team monitored the Plan of Removal on 11/11/23 as followed: Review of Resident #1's face sheet, progress notes, and care plan reflected RNC reviewed his health records to ensure staff revised and updated his records to reflect his incident on 10/16/23, follow-ups were conducted, and revisions were made. During interviews on 11/11/23 from 5:53 p.m. through 6:03 p.m., 3 LVNs, 1 Agency LVN, 1 Agency RN, and 2 CNAs all stated they were in-serviced on abuse, neglect, and unlocking/locking residents' beds before they started their shifts. During an interview on 11/11/23 at 5:56 p.m., RNC stated she in-serviced the ADM and DON on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by telephone. During an interview on 11/11/23 at 6:06 p.m., ADON stated she conducted and completed the facility's weekly DON/Designee review of 5 residents per week for 4 weeks on 11/10/23. ADON also stated the beds were locked and there was no action needed/taken for the 5 residents' beds. ADON stated she attended a QAPI meeting on 11/10/23 to discuss the plan of removal for the F689 IJ. ADON also stated she was in-serviced on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by the DON. An attempt to interview MD was made on 11/11/23 at 6:09 p.m., but MD did not return the surveyor's call prior to exit. During an interview on 11/11/23 at 6:10 p.m., DON stated she was in-serviced on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by the RNC. DON also stated she in-serviced staff on 11/10/23, 11/11/23 and in-servicing was ongoing until all staff were trained prior to starting their work shifts. DON stated she notified and updated the MD on 11/10/23. DON also stated she attended a QAPI meeting on 11/10/23. DON stated she completed the facility's daily census report on 11/10/23, checked all residents' beds, and ensured the beds were locked. DON stated the RNC reviewed Resident #1's face sheet, progress notes and care plan to ensure staff revised and updated his records to reflect his incident on 10/16/23, follow-ups were conducted, and revisions were made. During an interview on 11/11/23 at 6:16 p.m., HR stated she completed the facility's daily census report on 11/11/23, checked all residents' beds, and ensured the beds were locked. HR also stated she was in-serviced on abuse, neglect, and unlocking/locking residents' beds on 11/10/23 by the ADM and DON. HR stated she attended a QAPI meeting on 11/10/23 and attended the Report of Employee Education on 11/10/23 that was presented by the RNC regarding safety, hazards, bed locking and abuse and neglect. Review of the facility's Report of Employee Education from 11/10/23 reflected SW presented to 5 resident council members subjects regarding safety, hazards, and bed locks on 11/10/23. RNC presented to DON, TN, HR, BOM, SW, and ADM subjects regarding safety, hazards, bed locking and abuse and neglect. Review of the facility's in-services reflected staff were trained on locking and unlocking residents' beds, abuse, and neglect by DON an ADM by in person and over the phone on 11/10/23. Review of the facility's undated notification document reflected MD was notified of the F689 IJ on 11/10/23 by ADM and DON. Review of the facility's QAPI Improvement Plan reflected DON, BOM, ADON, SW, TN, HR, ADM, and MD were present and held a QAPI meeting on 11/10/23 at 8:00 p.m. Review of the facility's daily census reports from 11/10/23 through 11/11/23 reflected all residents' beds were checked to ensure they were locked on 11/10/23 by DON and on 11/11/23 by HR. Review of the facility's weekly DON/Designee review of 5 residents per week for 4 weeks reflected 5 residents' beds were checked to ensure they were locked on 11/10/23 by ADON. 1 of the 5 residents' beds checked was Resident #1. There was no action needed/taken for the 5 residents' beds. Review of the facility's undated ADM oversigh [TRUNCATED]

Based on observation, interview, and record review, the facility failed to ensure the residents were free from abuse for 2 (Residents #1 and #2) of 7 residents reviewed for abuse. The facility failed to ensure Residents #1 and #2 were protected from verbal abuse including verbally aggressive behavior, such as cursing, insulting, and intimidation from Residents #3 and #4. Residents #1 and #2 suffered continual negative psychosocial outcomes including fear, anxiety, feelings of hopelessness, and withdrawal from former social patterns. An IJ was identified on 10/20/23. The IJ template was provided to the facility on [DATE] at 9:57 PM. While the IJ was removed on 10/21/23 at 10:48 AM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. The failure placed all residents in the facility at risk for verbal abuse, and severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of depression (sad). Record review of Resident #1's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #2's undated face sheet revealed that he was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of a general anxiety disorder (produces fear, worry, and a constant feeling of being overwhelmed). Record review of Resident #2's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed no score. Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including vascular dementia (disrupts blood flow to the brain and affects memory, thinking, and behavior), psychotic disturbance mood (episodes of depression), mood disturbance (feelings of distress, sadness, or symptoms of depression and anxiety), anxiety (increased alertness, fear, and rapid heartbeat), and major depressive disorder (sadness). Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others; that indicated that the behaviors were not present. Record Review of Resident #3's care plan dated 09/26/23 revealed Resident #3 had a history of aggressive behavior toward another resident. Interventions included to intervene as needed to protect the rights and safety of others. Approach and speak in a calm manner; divert attention; and remove from the situation and take to another location as needed. Record review of the facility's incident report printed 10/20/2023 revealed: 08/12/23 authored by LVN E at 0:30 AM aggressive combative behavior 09/03/23 authored by LVN A at 7:30 AM aggressive behavior 09/21/23 authored by LVN B at 8:30 PM resident-to-resident altercation Record review of Resident #3's progress note printed 10/21/23 revealed: -09/03/23 at 7:30 AM Nurse Note authored by LVN A ,Resident got into a verbal altercation with another resident while receiving his morning medication. The resident was yelling at another resident because he didn't like the way he was being approached. This nurse separated the two residents by bringing one resident to the dining room. RP and ADON notified. -09/21/23 at 7:50 PM Nurse Note authored by LNV B, Resident claims that another resident ran over his leg with automatic wheelchair resident stated that he punched that resident in the right side of his jaw. No injuries noted to the resident left lower leg where he stated that the injury took place. RP made aware. Incident between residents was unwitnessed. NP notified no new orders received at this time. No c/o pain voiced at this time. -10/12/23 at 7:14 PM Nurse Note authored by LVN B, Staff witnessed resident yelling at another resident outside stating that the resident slammed his bedroom door and woke him up. This writer was at the nurse station and did not hear a door slam. Resident was outside this AM when the writer arrived to work and came in the facility 30 min later. This resident finally started to walk towards the back of the facility. -10/12/23 at 7:25 PM Nurse Note authored by LVN B, Resident approached nurse station where 2 staff members and a resident were at. Resident accused another resident of making a comment. Staff asked what he was referring to, and resident starting arguing with resident stating that she made some comment and I'm tired of it. Other resident told this resident to leave her alone, she never said anything towards him and the resident continued to argue and walk down the hallway. Resident walked in to another room to conversate. Record review of Resident #4's undated face sheet revealed that he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including altered mental status (change in mental function), bipolar disorder (shift in mood), and major depressive disorder(sadness). Record review of Resident #4's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Section E Behavior Symptom - presence and frequency revealed a 2 for verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; that indicated that the behaviors were present. Record review of Resident #4's care plan dated 08/16/23 revealed Resident #4 had a behavior problem related to aggressive behavior toward other staff and residents. Interventions were to intervene as needed to protect the rights and safety of others; approach and speak in a calm manner; divert attention; and remove from the situation and take to another location as needed. Record review of the facility incident report dated 09/03/23 authored by LVN A at 7:30 AM revealed an incident with Resident #4 aggressive behavior/yelling. Record review of Resident #4's progress note revealed: -10/12/23 8:32 AM Nurse Note authored by LVN B, Resident was in the dining room and threw away another resident plate of food. Other resident was walking asking dietary staff for jelly and was not seated at the table at the time. Other resident confronted this resident and this resident states you weren't sitting there and this what I do you crazy motherfucker. Staff attempted to separate residents from arguing and assisting them to walk away and this resident walks out in the dining room and states, Everyone know what I do here so quit yelling with your crazy motherfucking ass. Attempted to redirect resident to not talk to other residents in that manner and resident walks away swearing. Record review of the facility's concerns/grievances form dated 8/23/23 revealed Resident #1 made a complaint against Resident #3 and Resident #4. The form reflected Resident # 1 stated that [Residents #3 and # 4] are calling me a faggot because I am gay and make comments about my sexuality. Plan to resolve the DON and ADM offered Resident #1 to change rooms so Resident # 1 would not have to frequently see Resident #3 and Resident #4. Resident #1 refused the room change. No resolution to the name-calling behavior with Resident # 3 and Resident #4. An interview on 10/20/23 at 3:00 PM was attempted in Resident #3's room. While trying to ask questions Resident #3 was verbally aggressive and loud with the surveyor. Resident #3 was very upset and stated that the surveyor was just like the rest of them and stated, don't do anything. The surveyor exited Resident #3's room and immediately started speaking with the ADON. Resident #3 came into the hall by the nurse's station, being very loud and verbally aggressive while the surveyor was speaking with the ADON. Resident #3 followed the ADON and surveyor down the hall. The surveyor and ADON asked Resident #3 to calm down as she didn't want the other residents to get upset. When the surveyor was on the phone in the conference room communicating the events to the program manager Resident #3 entered the conference room speaking loudly with his cell phone to his ear. Resident #3 was advised by the surveyor she was taking a call and he left the conference room. An interview on 10/20/23 at 4:30 PM revealed Resident #1 and Resident #2 came to the conference room where the surveyor was seated and wanted to let the surveyor know what they observed with Resident #3. Resident #1 and Resident 2 observed the incident with the surveyor. Resident #1 and Resident #2 stated that was the behavior that Resident #3 displayed with them. Resident #1 and Resident #2 both appeared frantic and spoke very fast in a frightened tone. Resident #1 and Resident #2 stated they observed how Resident #3 was loud with the surveyor and followed the surveyor, and was very hostile. Resident #1 and Resident #2 both stated they would be retaliated against because staff saw them waiting to talk with the surveyor. Resident #1 and Resident #2 stated they were tired of the name-calling, being cursed at, and being harassed by Resident #3 and Resident #4. Resident # 1 stated he filed a grievance sometime back in August 2022, (could not recall the day) and the only thing offered was a room exchange. Resident #1 stated why would a room change fix the problem as he would still have to see Resident #3 and Resident #4. Resident #1 stated Resident #3 and Resident #4 walked the entire facility daily. Resident #1 and Resident #2 stated nothing had been done and they both had made several complaints to the ADM and DON. Resident #1 and Resident #2 both stated management was not doing anything about Resident #3 and Resident #4 and they both did not feel safe at the facility. Resident #1 and Resident #2 both stated they were fearful of Resident #3 and Resident #4 because they called out of their names and were followed behind saying vulgar things. Resident #2 stated Resident #3 and Resident #4 would walk behind her and call her a bitch and a [NAME]. Resident #2 stated that was very degrading to think of her as those things. Resident #2 stated the harassment of being called out of her name had made her emotionally down. Resident #2 stated when Resident # 3 and Resident #4 were saying vulgar things about her she started to think about how people really felt about her. Resident #2 stated that Resident #3 and Resident #4 walked around the facility a lot and just last night 10-19-23 were saying cuss words towards her. Resident #2 stated it was intimidating and very uncomfortable. Resident #3 and Resident #4 had been getting away with it for too long and it had to be stopped. Resident #2 did not feel the facility was protecting her and with Resident #3 and Resident #4's behaviors she was in fear. Resident #2 stated Resident #3 and Resident #4's behavior would get worse and somebody may eventually get hurt. Resident #1 stated that name-calling and harassment of his sexuality had been happening for almost a year now. The behavior with Resident #3 and Resident #4 started in December 2022 (could not recall the date). Resident #3 and Resident #4 would call him names such as fagots, sissy, gay, and horrible profanity towards him. Resident #1 stated that had affected him emotionally because that was who he was and he could not change who he was. Resident #1 did not feel comfortable as he was in a wheelchair, and Resident #3 and Resident #4 followed behind him talking trash about him and calling him names. Resident #1 was afraid of Resident #3 and Resident #4 and he felt the facility was making it worse by not doing anything about it. Resident #1 told the DON and ADM several times about Resident #3 and Resident #4's behaviors. When Resident #1 was by himself and not with Resident #2 they were even worse because they said things such as they will beat the [NAME] up. When Resident #1 was not with Resident #2 they were both in their rooms to avoid Resident #3 and Resident #4. Resident #1 and Resident #2 avoided being followed around and being imitated by Resident #3 and Resident #4. Resident #1 and Resident #2 stated that it was not safe for them at the facility because someone would eventually get hurt. Resident #1 and Resident #2 were not comfortable with it and it made them not want to be at the facility any longer, but they had no other place to go. Resident #1 stated he was involved in an incident months back on hall 800 could not recall the date) with Resident #3 where he had hit him He stated the state agency had investigated the incident and he had spoken with a surveyor. An interview on 10/20/23 at 5:00 PM the DON stated when the grievance was made back in August on the 23rd, 2023, Resident #1 had made a complaint that Resident #3 and Resident #4 had been calling him names. The DON offered a room change so he would not frequently see Resident #3 and Resident #4, and Resident #1 declined. The DON stated no residents ever came to her saying they were not safe. The DON stated Resident #1 had not made any further concerns or complaints. Resident #3 and Resident #4 were talked to and nothing else was said to her after. The DON stated Resident #1 was at the front all day and never said anything to her about safety concerns. The DON stated she did not witness the incident with Resident #2 and Resident #3 during the mock trial resident council meeting. The DON stated there were not any witnesses that Resident #3 was calling Resident #2 out of her name. An interview on 10/20/23 at 5:17 PM the ADM stated that Resident #4 and Resident #5 were care planned for behaviors and interventions to redirect, seeing psych services, and taking medications for behaviors. The ADM stated that Resident #3 and Resident #4 did not like Resident #1. The ADM stated she knew about that name-calling when Resident #1 filed a grievance back in August 2023. Resident #1 was given the option to move rooms and he declined. The ADM stated Resident #4 and Resident #5 were talked to by the DON. The DON had talked to Resident #2 on 10-19-23 about the incident in the resident council mock meeting where Resident #4 had supposedly cursed Resident #2 out. The ADM stated corporate did not tell them anything like that happened in the meeting. The ADM stated it was known that Resident #1, Resident #3, and Resident #4 did not like each other The ADM stated that Resident #1 would say things back to Resident #3 and Resident #4 as well. The ADM stated no residents had mentioned anything to her about not being safe at the facility. An interview on 10/20/23 at 6:00 PM the ADON stated around September 2023 date (unknown) Resident #2 overheard Resident #3 fussing with nursing staff and Resident #2 felt nervous about it. Resident #2 did not mention any concern about her safety. The ADON stated no report was made due to Resident #2 not mentioning she was scared. The ADON stated she knew Resident #1 made a grievance about Resident #3 and Resident #4 calling him names. The ADON stated no one had made any complaints or concerns to her since the incident. An interview on 10/20/23 at 6:05 PM LVN A stated Resident # 3 and Resident # 4 used foul language while talking. LVN A stated he had observed behaviors from resident to resident. LVN A recalled Resident #3 was in a verbal altercation with a resident while receiving his medication. Resident #3 was yelling at the other resident. LVN A redirected them by taking one resident to the dining room. LVN A stated state came in and investigated an incident with Resident #3. An interview on 10/20/23 at 7:00 PM revealed Resident #4 did call Resident # 1 names because he didn't like Resident # 1 or Resident #1's sexuality. Resident #4 stated that he had called Resident #1 even worse things as he stated he just don't like the [NAME]. Resident #4 started using vulgar profanity while talking about Resident #1. Record review of the facility's abuse policy revised August 2006 reflected, Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment, and involuntary seclusion. On 10/20/23 at 9:57 PM, the ADM and DON were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template. On 10/21/23 at 10:48 AM the following plan of removal was accepted: Plan for REMOVAL Plan to remove immediate jeopardy. The facility failed to ensure 2 residents were free from verbal abuse. Resident #1 and Resident #2 are experiencing verbal and emotional abuse by Resident #3 and Resident #4 resulting in the residents feeling unsafe at the facility. All residents residing in the facility can be affected by this deficiency. F600 On 10/20/2023 the Administrator and Director of Nursing notified the Medical Director of the immediate jeopardy. On 10/20/2023 the Director of Nursing/Designee assessed the resident (R1) and resident (R2) for any changes in condition, provided emotional support - no findings, the MD notified and responsible party. Resident (R3) and resident (R4) were placed 1: 1 for supervision till evaluated by behavioral services. Staff will be with Residents #3 and #4 at all times, within sight during their stay at the facility; staff will be trained on 1:1 supervision as assigned. The Administrator or Director of Nursing will assign staff to complete 1: 1 supervision. On 10/20/2023 the Administrator/Designee completed safe surveys on all residents in the facility - no other allegations of abuse or fear/not feeling safe in the facility due to those residents. The Medical Director was notified; the Ombudsman was notified. No changes in condition were noted. If patient is not feeling safe, staff will stay with the resident to reassure they are safe and cared for, behavioral services and/or social services will provide emotional support. The DON/Designee will be responsible to train staff on the weekends. On 10/20/2023 the [NAME] President of Clinical Operations (VPCO) completed an in-service with the Director of Nursing and Administrator on abuse and neglect prevention. Starting on 10/20/2023 the Director of Nursing/Designee will initiate in-service with staff on abuse and neglect preventions, keep residents safe, identifying signs and symptoms of fear or feeling not safe and re-direct, assure patients' safety and support. All staff, including agency, new hire staff, and PRN will be in-service and will not be allowed to start work till done so. The Administrator will ensure all staff completed in-services and training prior to start working. The training will be completed by 10/21/2023. Ad-Hoc QAPI meeting was held on 10/20/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and MOS (sic) Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 10/20/2023, IDT (Interdisciplinary team), including the Administrator, Director of Nursing, Assistant Director of Nursing, and MOS (sic) Coordinator will meet with all residents to determine of any allegations of abuse or feeling not safe while in the facility daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. If action is needed, the Administrator/Designee will meet with the resident and make sure patient feels safe and provide emotional support, including involving behavioral services and/or social services, and the Medical Director and responsible party will be notified, and if allegation of abuse is identified, the Administrator will notify the appropriate authority. The Director of Nursing/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks for allegation of abuse or not feeling safe while in the facility. This will be initiated on 10/20/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. 10/20/2023 RDO will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Administrator/Designee met with the resident council on 10/20/23 and then monthly to review abuse prevention policy and patients' safety while in the facility. The Administrator will be responsible for ensuring this plan is completed on 10/21/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. POR monitoring: Record review of in service on de-escalation techniques, abuse, and neglect started on 10/20/23 and completed on 10/21/23. An observation on 10/21/23 at 1:15 PM revealed Resident #3 in a 1-to-1 with CNA A outside of Resident #3's room. An observation on 10/21/23 at 1:35 PM revealed Resident #4 in a 1-to-1 with LVN F outside of the facility taking a walk. An observation on 10/21/23 at 1:40 PM revealed Resident #3 in a 1-to-1 with CNA A outside of Resident #3's room. An observation on 10/21/23 at 2:10 PM revealed Resident #3 in a 1-to-1 with CNA A walking to Resident #3's room. An observation on 10/21/23 at 2:15 PM revealed Resident #4 in a 1-to-1 with LVN F walking by the nurse station. An observation on 10/21/23 at 2:30 PM revealed Resident #3 in a 1-to-1 with CNA A walking by the nurse station. An observation on 10/21/23 at 2:35 PM revealed Resident #4 in a 1-to-1 with LVN F outside Resident #4's room. An observation on 10/21/23 at 2:45 PM revealed Resident #3 in a 1-to-1 with CNA A walking by the conference room. An observation on 10/21/23 at 2:48 PM revealed Resident #4 in a 1-to-1 with LVN F walking throughout the halls. An interview on 10/21/23 at 1:15 PM CNA A stated he was trained on abuse and neglect and de-escalation on 10/21/23. CNA A know the signs of abuse and know to report it to abuse coordinator, and make sure residents are safe. CNA A was able to identify the signs of abuse and gave examples. An interview on 10/21/23 at 1:30 PM RN A stated she was trained on abuse, neglect, and de-escalation on 10/21/23. RN A know the signs of abuse, and neglect, know to report to abuse coordinator . RN A stated she was trained on how to handle aggressiveness by calming the residents to remain safe. An interview on 10/21/23 at 1:36 PM CMA A stated she was trained on abuse, neglect, and de-escalation before the start of her 6 AM shift. CMA A stated, know the signs of abuse and neglect, know to report immediately to the abuse coordinator if witnessed, and know how to handle aggressive residents by calming them down. An interview on 10/21/23 at 2:09 PM LVN F stated she was trained on abuse and neglect on 10/21/23. LVN F stated that she knew the signs of abuse and neglect and know who to report it to immediately to the abuse coordinator. Record review of safe surveys of all residents was conducted on 10/20/23. On 10/21/23 The Administrator was informed the IJ was removed 10/21/23 at 10:48 AM However, the facility remained out of compliance at actual harm that is not immediate and a scope of a pattern due to the facility's need to monitor the evaluate the effectiveness of their plan of removal.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 residents reviewed for medication administration. The facility failed to identify Resident #1 had been cheeking or pocketing his medication during medication pass on multiple occassions without staff kowledge and it is unknown if Resident #1 took any of the pills. An IJ was identified on 08/15/2023 . While the IJ was removed on 08/16/2023 at 7:45 PM, the facility remained out of compliance at a severity level of no actual harm that is not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice placed residents at risk to from suffer serious harm, serious impairment, or death from drug, alcohol interactions, and prescription narcotic pain medication interaction. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including Rhabdomyolysis (damaged muscle tissue releases its proteins and electrolytes into the blood. and can damage the heart and kidneys and cause permanent disability or even death, chronic alcohol usage is one of the leading causes of rhabdomyolysis due to the effects of drinking on muscular tissues), Enterocolitis due to Clostridium difficile (a disturbance of the normal bacterial flora of the colon, colonization by C difficile, and the release of toxins that cause mucosal inflammation and damage), other lack of coordination, acute kidney failure, alcoholic fatty liver, metabolic encephalopathy (a problem in the brain caused by a chemical imbalance in the blood), alcohol use, unspecified with other alcohol-induced disorder, and other seizures. Review of Resident #1's quarterly MDS assessment, dated 05/24/2023 reflected a BIMS score of 10 (suggesting moderate cognitive impairment) and was admitted to the facility after an acute hospitalization . R#1 received PRN pain medications or was offered and declined. Pain assessment interview reflected R#1 revealed that R#1 had had no pain or hurting at any time in the last 5 days. R# 1 received opioid medication 7 for the last 7 days. Review of R#1's quarterly care plan problem start date 08/29/2022 reflected Cognitive Loss/Dementia - Resident #1 had cognitive loss or alteration in thought processes as evidenced by impaired decision making, cognition worsening in the evening. Review of R#1's quarterly care plan problem start date 08/14/2022 reflected R#1 had drug and alcohol seeking behavior. R#1 had been suspected by staff of being intoxicated while in facility. Review of R#1's hospital records received from the facility dated 06/09/2022 revealed patient brought into hospital and found to be intoxicated at an alcohol level above 200 (a person may experience blackouts). R#1 was admitted to the facility on [DATE]. Interview on 08/15/2023 at 12:24 pm with the ADM revealed a charge nurse caught a resident (Resident #1) with two 1.75-liter bottles of Bacardi whiskey. ADM revealed she was nsure how R#1 obtained the alcohol because he does not have any income. The facility does not have an alcohol policy and R#1 is on pain medication; narcotics. It was revealed that the NP placed an order for R#1 to go to the emergency room for a toxicology screen (refers to various tests that determine the type and approximate amount of legal and illegal drugs a person has taken). but the emergency medics refused to take R#1 and stated it was not an emergency. NP placed R#1's narcotic pain medications on hold for 48 hours. R#1 received Tylenol for pain. Interview on 08/15/2023 at 1:17 pm with the CN revealed she found R#1 with two 1.75-liter bottles of Bacardi. One bottle was empty and the second was one 2/3 empty. CN revealed that R#1 was upset because his medication was changed, and normally he understood and was fine, but he was angry and cursing her out and had not previously exhibited this behavior. CN revealed R#1's speech was a little slurred. CN said the medication aide reported to her that R#1 said something inappropriate to her and the medication aide reported she smelled alcohol on R#1's breath. CN revealed that this was not R#1's baseline (state of behavior which is steady in form and frequency). CN revealed that when she went to his room, she found a cup full of Robaxin (a muscle relaxer that works by blocking nerve impulses (or pain sensations) that are sent to your brain) and in a suitcase, 2 bottles of Bacardi. The CN revealed she called the DON and NP. CN revealed she did not know how many Robaxin pills were in R#1's possession but she observed a 30 ml. cup full of pills. When asked CN how she knew what pills were in the cup she revealed they matched the pills with what he was already taking; the Robaxin. CN revealed she did not know how R#1 got that many Robaxin. She did not ask him. When asked about the alcohol, he said he and a friend were outside drinking, but did not tell her how he obtained the alcohol. CN revealed she told the DON about both the Robaxin and the alcohol, but no one asked her about how R#1 got the Robaxin. CN revealed she had not previously seen R#1 with stored Robaxin or any other medications and was not aware of any previous incidents involving alcohol. Interview on 08/15/2023 at 2:00 pm with R#1 revealed he just had one cup of the Bacardi and he was not drunk. He revealed he had the liquor in his room for a while but hid it in a suitcase. When asked where he obtained the Robaxin, he said from the facility. When asked how he obtained so many of the Robaxin, he said he kept the muscle relaxers in his mouth (referred to by the pharamacist at cheeking or pocketing - an attempt to not swallow prescribed medication by concealing it in the mouth for purposes of diverting, hording , and swallowed his other medications, He stored the Robaxin in a container in his room. He said when given his medication from the staff, the staff did watch him swallow his medication. When asked why he cheeked or pocketed the Robaxin, R#1 said he had no intent to harm himself and the CN made, a mountain out of a mole hill. R#1 revealed he brought the alcohol with him and had been drinking it over time, Interview on 08/15/2023 at 4:37 pm with the facility's Pharmacist revealed that both Robaxin and alcohol cause sedation and decreased stimulation of the central nervous system. She said it wasnot a good idea to mix the two substances and muscle relaxers and alcohol are on occasion, combined as a form of drug abuse. She revealed she was not sure if the combination would be lethal, but it was not a good combination. She revealed that cheeking or pocketing pills was a drug seeking behavior. Interview on 08/15/2023 at 5:22 pm with the NP revealed that R#1 told her that prior to his admission to the facility, he would drink alcohol because of pain. She revealed she knew he was in pain, but if he drank an unknown amount of alcohol, consumed an unknown number of cheeked or pocketed prescription medication on top of the prescribed pain medication given, he was putting her in a pickle. It is the facility's responsibility to keep him safe, but he could notbe kept safe if the facility did not know the number of drugs and the amount of alcohol he had consumed. NP revealed R#1 was made a conscious decision to consume alcohol and cheek or pocket medications. When asked if there was an immediate concern for R#1's wellbeing, NP said there was immediacy the second the consumption of an unknown amount of alcohol and muscle relaxers occurred. NP said, regarding the muscle relaxers, who is say if he was going to horde 50 of them. Review of progress note psychiatric evaluation dated 08/14/2023 reflected R#1 had a history of alcohol use. Staff reported he had alcohol problems and recently was intoxicated; pain medication were held for 24 hours. He denied drinking a lot of alcoholic drink. He acknowledged he had a bottle of alcohol drink in his room, but reported he did not drink it all the time. Resident #1 denied ever getting drunk or intoxicated And that reporting staff lied against him. Resident #1 reported his last drink was yesterday . He was sad because his pain medication was held. I didn't take any alcohol, the nurse came to my room and found alcohol and decided to make claim that I am drunk, but I am not. Resident #1 reported anxiety because he is in pain and did not receive his pain medicine. Reported poor sleep and I can't sleep because I am in pain, and I don't have my pain medicine. Review of physician order report dated 08/12/2023, open ended order, reflected may alter medication by crushing, opening, or administering in fluid or food unless contraindicated. Review of progress note dated 08/15/2023 revealed R#1 admitted to hiding liquor in his room and drinking while in the facility and had a friend who signed him out of the facility and took him to buy liquor. Review of order for central acting skeletal muscle relaxant 750 mg. not crushed start dated 01/13/2023 end dated 08/14/2023 three times a day. Review of order start date 06/26/2023 open ended and on hold from 08/14/2023 through 08/15/2023 for hydrocodone-acetaminophen Schedule II tablet (high potential for abuse which may lead to severe psychological or physical dependence); 5-325 mg. amount 1 tab; oral, not to exceed 3,000 mg. in 24-hour period every 4 hours. Review of facility's policy dated December 2012 reflected the director of nursing services will supervise and direct all nursing personnel who administer medications and/or have related functions, medications must be administered in accordance with the orders, including any required time frame, medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. On 08/15/23 at 7:21 PM an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided the IJ Template, and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and was accepted on 08/16/2023 at 7:08 PM: On 08/15/2023 an abbreviated survey was initiated at the facility. On 08/15/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that Regulatory Services determined that the condition at the facility constituted an immediate threat to resident health and safety. Plan to remove immediate jeopardy. The facility failed to have adequate supervision to prevent potential accidents. Residents with alcohol and/or drug dependency have the potential to suffer serious harm, serious impairment or death from drug interactions. F689 On 8/15/2023 at 7:21pm the IJ was called; the Administrator notified Medical Director of immediate jeopardy. On 8/15/2023 Director of Nursing/Designee assessed the resident (R1) for any changes in condition - no findings, MD notified and Responsible party. On 8/15/2023 Director of Nursing/Designee assessed all residents in the facility who have alcohol and/or drug dependency for any changes in condition, including pocketing medications. No Changes in condition noted. On 8/15/2023 RNC (Regional Nurse Consultant) will complete in-service with Director of Nursing, Assistant Director of Nursing, and Administrator on alcohol and/or drug dependency and medication administration, including monitoring resident during medication administration by asking resident to open their mouth to visualize medication were ingested and confirmation from resident that medication has been ingested, and identifying residents who pocket their medications in the mouth, MD notification, and update Care Plan, alcohol storage will only be allowed at nursing station in secure area and provided to residents as ordered by Physician. When a resident goes out of the facility and upon return staff will interview and observe resident for any alcohol products on-hand and secure at the nursing station. On 8/15/2023 DON/Designee reviewed all residents in the facility who have alcohol and/or drug dependency for pocketing medication - no other resident was identified to pocket medications. Starting 8/16/2023 IDT will review all new admissions and residents identified as alcohol and/or drug dependent for pocketing medications and update the Care Plan for pocketing medications interventions during morning meeting Monday through Friday for 1 month. Starting on 8/15/2023 the Director of Nursing/Designee will initiate in-service with nurses and Medication Aides, including new hires, PRN, and agency staff on adequate supervision of a resident with Alcohol and/or Drug dependencies during medication administration by monitoring patient for swallowing medications and verbal or visual confirmation of ingestion, MD notifications, and alcohol storage will only be allowed at nursing station in secure area. Ad-Hoc QAPI meeting was held on 8/15/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and MDS Coordinator to review the deficiency and the plan for removal of immediacy. Starting on 8/15/2023, IDT (Interdisciplinary team), including Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator will review current and admitted residents with diagnosis of alcohol and/or drug dependency for behaviors of pocketing medications and ensure updated Care Plan for medication administrations/behaviors of pocketing medications daily Monday to Friday, and Manager on Duty Saturday and Sunday x 1 month. The findings will be immediately brought up to the Administrator for further action, if necessary, as an on-going process. The Director of Nursing/designee will monitor compliance by completing an audit of five (5) residents per week for four (4) weeks who have diagnosis of alcohol and/or drug dependency for pocketing medications and presence of care plan addressing pocketing medications. This will be initiated on 8/15/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for the next 2 months. 8/15/2023 RNC will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. Administrator/Designee will meet with resident council on 8/16/23 and then monthly after to review substance abuse policy and procedure, including alcohol storage at nursing station and process of nursing checking residents for pocketing medications. The Administrator will be responsible for ensuring this plan is completed on 8/15/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal from 06/07/2023 - 06/12/2023 included the following: Reviewed documentation of assessment of all residents in the facility who have alcohol and/or drug dependency for changes in condition, including pocketing medications. Reviewed in-service and in-service materials and interviewed DON, ADON, and ADM who confirmed they attend the in-service on alcohol and/or drug dependency and medication administration, including monitoring resident during medication administration by asking resident to open their mouth to visualize medication were ingested and confirmation from resident that medication has been ingested, and identifying residents who pocket their medications in the mouth Interview with Medication Aides who confirmed they attended an in-service staff on adequate supervision of a resident with Alcohol and/or Drug dependencies during medication administration by monitoring patient for swallowing medications and verbal or visual confirmation of ingestion, MD notifications, and alcohol storage will only be allowed at nursing station in secure area. Interview with LVN who said she attended an in-service and discussed pocketing medications and that residents should have an order from the doctor on if they can consume alcohol. She said the in-service was helpful and made her realize that she needed to be more observant. Reviewed Ad-Hoc QAPI meeting notes that reflected on 8/15/2023 a meeting with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, Regional Nurse Consultant, and MDS Coordinator to reviewed the deficiency and the plan for removal of immediacy. Reviewed the 8/15/2023 monitoring audit of five (5) residents who had diagnosis of alcohol and/or drug dependency for pocketing medications and presence of care plan addressing pocketing medications that was to be on 8/15/2023. The ADM was informed the Immediate Jeopardy was removed on 08/16/2023 at 7:45 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice for 1 (Resident #2) of 4 residents reviewed for pain, in that: The facility failed to provide effective pain management for Resident #2 who had dental abscesses by running out of her prescription pain medicine which caused her to have pain for 3 days and limited her enjoyment of food. This failure placed residents at risk for prolonged and unnecessary pain and suffering, decreased mobility, and a decreased quality of life. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including anxiety, depression, weakness, stroke, pain unspecified, and dysphagia (trouble swallowing). Review of Resident #2's MDS assessment, dated 07/20/23, reflected a BIMS of 9 , indicating a moderate cognitive impairment. Section J (Health Conditions) reflected she was not on a scheduled pain medication. Review of Resident #2's quarterly care plan, revised 04/12/23, and next care plan 07/11/23 reflected she was at risk for alteration in comfort related to generalized pain and that she receives pain medication Tylenol, lyrica and hydrocodone scheduled (the section of the care plan related to alteration in comfort was added to care plan 08/03/23 at 2:24 pm after investigator intervention). The interventions were administer pain medication as ordered. Review of Resident #2's orders reflected an order for 650 mg of Tylenol three times a day for pain, unspecified and started on 05/11/23 with no end date. It also reflected an order for baclofen 10 mg three times a day for other muscle spasm and started on 05/11/23 with no end date. It further reflected an order for hydrocodone 5-325 mg twice day for pain, unspecified and started 05/11/23 with no end date. In addition, pregabalin 50 mg twice a day started 07/28/22 with no end date was also ordered for neuralgia and neuritis (nerve pain and nerve inflammation). Review of Resident #2's 07/04/23 - 08/03/23 Medication Administration Record revealed the following dates and times her hydrocodone was not administered because the drug was unavailable (as documented in the Medication Administration Record): 07/31/23 7:00 pm 08/01/23 7:00 am 08/01/23 7:00 pm 08/02/23 7:00 am 08/02/23 7:00 pm It further revealed on 08/03/23 at 7:00 am her hydrocodone was administered. During an interview and observation 08/03/23 at 1:30 pm with Resident #2 she stated that she had dental abscesses that needed treatment and she was on the list to see the dentist. She also stated that she did not get her norco (hydrocodone) for the last 3 days because the nurse said it was not available and because of this her pain was an average of 7-8 out of 10 and at times went up to 10 out of 10. In addition, she stated it was difficult to eat due to the pain, which the norco helped enough for her to eat on one side of her mouth. Resident #2 was tearful and grimacing during the interview and occasionally grabbed her jaw from the pain. During an interview on 08/03/23 at 1:50 pm, the DON stated she was not aware that Resident #2's medication was not available and she would go assess the resident. DON stated medication was available in the emergency kit, so if she had known it was not available they could have pulled from the kit. Record review of Resident #2's progress notes revealed on 08/03/23 at 2:51 pm by the DON an order for an increase of norco from twice a day to three times a day scheduled for pain. During an interview on 08/04/23 at 4:00 pm, the ADM stated that there were issues with the pharmacy and it not automatically receiving orders from the EHR. She stated the corporate office was aware and were on phone calls weekly to address the issues. These calls had been occurring since early spring. Review of the facility's Pain Assessment and Management Policy, dated March of 2015, reflected the following: Purpose: . identify pain in resident, and develop interventions that are consistent with the resident's goals and needs . .assess resident's pain using consistent approach . reflect sources, type and severity of pain .administer pain medication around the clock, not PRN .implement the medication regimen as ordered, carefully documenting the results of the interventions.

Based on interview and record review, the facility failed to ensure that resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, for one (Resident #1) of two residents reviewed for quality of care, in that: The facility failed to monitor PT/INR values to ensure anticoagulant medication daily dosage was appropriate for Resident #1. An IJ was identified on 07/19/2023. The IJ template was provided to the facility on [DATE] at 6:12 PM. While the IJ was removed on 07/21/2023, the facility remained out of compliance at a scope of isolated with no actual harm with the potential for more than minimal harm that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure placed resident at risk of heart attack, stroke, deep vein thrombosis (occurs when a blood clot (thrombus) forms in one or more of the deep veins in the body, usually in the legs) or pulmonary embolism (a sudden blockage in your pulmonary arteries, the blood vessels that send blood to your lungs), and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including myocardial infarction (decreased or complete cessation of blood flow to a portion of the myocardium (muscular tissue of the heart). myocardial infarction may be silent, and go undetected, or can be a catastrophic event leading to hemodynamic deterioration (any cardiovascular condition that affects how well your blood flows) and sudden death), primary, epilepsy (a disorder of the brain characterized by repeated seizures), conversion disorder with seizures or convulsions, cognitive communication deficit, dementia, presence of prosthetic heart valve (mechanical valve), acquired hemophilia (bleeding disorder in which the blood does not clot properly), and hypertension (when the pressure in your blood vessels is too high). Review of Resident #1's MDS assessment revealed a BIMS score of 99 revealed Resident #1 chose not to participate, or 4 or more items in the score were coded 0 because Resident #1 chose not to answer or gave a nonsensical response. Section N of her MDS indicated that she received anticoagulants 7 days. Review of Resident #1's quarterly care plan, created 05/19/2023, reflected no care plan for Resident #1's diagnosis of epilepsy, seizure activity or anticoagulant therapy (having the effect of inhibiting the coagulation (process of blood changing to a solid or semi-solid state) of the blood). Record review of Resident #1's physician orders dated 5/21/23 revealed an order for PT/INR to be drawn daily until INR greater than 2.5 then PT/INR to be drawn every other day. Record review for Resident #1 revealed 8 different lab results for PT/INR dated 5/22/23 revealed INR of 2.5, PT/INR dated 5/23/23 revealed INR of 2.0, PT/INR dated 6/15/23 revealed INR of 1.1, PT/INR dated 6/22/23 revealed INR of 2.1, PT/INR dated 6/27/23 revealed INR of 2.2, PT/INR dated 6/30/23 revealed INR of 1.7, PT/INR dated 7/10/23 revealed INR of 2.5, PT/INR dated 7/17/23 revealed INR of 1.8. Review of Resident #1's progress notes dated 06/17/2023 reflected dining room staff called for nurse to go to the dining room. Resident #1 was found in her chair having had a seizure. Resident #1 was lowered to the floor and continued to have a seizure for a total of 5 minutes. Review of Resident #1's progress notes dated 06/25/2023 reflected Resident #1 had seizure activity when she fell out of her wheelchair, Resident #1 stated she hit her head. Review of Resident #1's progress notes dated 06/27/2023 reflected nurse called into Resident #1's room and found Resident #1 lying on the floor between her bed and the wall. Note reflected that Resident #1 told the med tech she felt like she was going to have a seizure. Note reflected that Med tech reported he turned around and he found Resident #1 on the floor. Note reflected that prior to the fall Resident #1 was sitting in her chair. When evaluated Resident #1 did not respond to her name and had her eyes closed. Note reflected that Resident #1 had a history of seizures. Review of Resident #1's progress notes dated 06/28/2023 reflected S/P seizure/fall yesterday and sent to the emergency room . Review of Resident #1's progress notes dated 07/02/2023 reflected nurse notified by staff that Resident #1 was on the floor and when at Resident #1's room she was found lying on her back between her bed and the wall. Resident #1 appeared to have had a seizure, was not responding to questions asked as usual and seemed slow to respond. Resident #1 complained of mild pain to a back, left hip area and head and was not able to perform range of motion. Resident #1 on anticoagulant therapy. Review of Resident #1's progress notes dated 07/05/2023 reflected Resident #1 had a seizure and hit her head on the table. Resident #1 was assessed and denied any pain. Note reflected staff would continue to monitor and all safety measure remain in place. Review of Resident #1's progress notes dated 07/11/2023 1:36 PM reflected Resident #1 was having lunch in dining room and began having a seizure. Seizure lasted approximately 3 minutes. Review of Resident #1's progress notes dated 07/11/2023 4:36 PM reflected Resident #1 was observed lying on floor unconscious, breathing normally. Review of Resident #1's progress notes dated 07/13/2023 reflected staff in dining room yelled for help and nurse found Resident #1 on the floor in prone position. Appeared to have had an absent seizure, Resident #1 was in and out of consciousness. Resident complained of pain to her head, no visible injury noted. Resident #1 was on Coumadin. Review of Resident #1's progress notes dated 07/17/2023 reflected Resident #1 found slumped over in a rocking chair outside. It seemed like the resident had a seizure. Review of Resident #1's progress notes dated 07/18/2023 12:56 PM reflected Resident #1 had a Grand Mal seizure (a loss of consciousness and violent muscle contractions) with episode lasting approximately 20 minutes. Review of Resident #1's progress notes dated 07/18/2023 8:00 PM reflected Resident #1 was found in room laying on floor next to air conditioning unit. Resident #1 said she had a seizure and hit her head. Resident #1 assessed with no apparent markings. In an interview on 7/19/23 at 4:35 PM, the DON stated if someone had a history of stroke and prosthetic valve replacement and coumadin is not being monitored or treated properly, they could have blood clots, stroke, and death. She said if an order for PT/INR stated to do labs daily until INR is greater than 2.5, labs should be done daily until INR reached 2.6. She said Resident #1 did not have an INR greater than 2.5 since she had lived in facility and PT/INR should have been checked daily. She said she did not know why PT/INR had only been checked 8 times in the 59 days Resident#1 had lab work ordered. She said the lab order in Resident #1's chart was not the order they were using but she could not produce an alternative order. Record review of facility Lab and Diagnostic Test Results - Clinical Protocol reflected the physician will identify and order diagnostic and lab testing based on diagnostic and monitoring needs and the staff will process test requisitions and arrange for tests. A nurse will review all lab and diagnostic test results and the individual's current condition and any recent changes in status, including vital signs and mental status, major diagnoses, pertinent current medications, other recent pertinent lab work, actions already taken to address results and treat the resident. Nurses will review how test results might relate to the individual's current status, treatments, or medications. On 07/19/23 at 6:12 PM an Immediate Jeopardy (IJ) was identified. The ADM was notified and provided the IJ Template and a Plan of Removal (POR) was requested at that time. The following Plan of Removal was submitted by the facility and was accepted on 07/21/2023 at 1:19 PM: On 07/18/2023 an abbreviated survey was initiated at the facility. On 07/19/2023 the surveyor provided an Immediate Jeopardy (IJ) Template notification that Regulatory Services determined that the condition at the facility constituted an immediate threat to resident health and safety. Plan to remove immediate jeopardy. Based on the comprehensive assessment of a resident, ensure that resident receives treatment and care in accordance with professional standards of practice. The facility failed to ensure proper PT/INR Coumadin therapy for Resident #1. Residents who are prescribed Coumadin, and not being monitored or treated properly, have potential for serious injury, serious harm, serious impairment, or death. For 1 of 1 resident, it could cause failure of prosthetic heart valve, excessive bleeding, stroke, and death. 2 residents on Coumadin therapy in the facility could be affected by this deficient practice. F684 On 7/19/2023 @ 20:00 the Administrator and Director of Nurses notified Medical Director of immediate jeopardy. On 7/19/2023 VPCS (Vice President of Clinical Services, RN) completed in-service with Director of Nursing and Assistant Directors of Nursing on Coumadin Therapy, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness, monitoring and assessing residents for changes in condition and follow MD orders for medication dose and appropriate lab draws, and communication on lab results. On 7/19/2023 Director of Nursing/Designee assessed the Resident 1 for any changes in condition, MD notified and Responsible party. Coumadin order and PT/INR lab work reviewed with MD and orders updated for Resident 1 in EHR. On 7/19/2023 Director of Nursing/Designee assessed all residents who are on Coumadin Therapy for any changes in condition, check their Coumadin order and PT/INR lab work order. No changes in condition noted. Director of Nursing/Designee assessed residents who are on medications that require lab monitoring for dosage adjustments and therapeutic effectiveness for any changes in condition - none noted. MD notified. Starting on 7/19/2023 the Director of Nursing/Designee will initiate in-service with nurses, including new hires, PRN, and agency nurses on Coumadin Therapy, physician orders and PT/INR lab draws tracking and communication, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness. Ad-Hoc QAPI meeting was held on 7/19/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, RRC (Regional Reimbursement Consultant), and VPCS (Vice President of Clinical Services) to review the deficiency and the plan for removal of immediacy. IDT will review all current and new admissions/re-admissions for Coumadin Therapy and physician orders for dosages and PT/INR lab work and medications that require lab monitoring for dosage adjustments and therapeutic effectiveness starting 7/19/2023 during Morning meeting Monday through Friday x 1 month to make sure Coumadin Therapy Protocol is followed, including Checking Coumadin order, PT/INR and medication specific Lab test order and results documentation, communication to physician results and any changes in condition, update orders in EHR and administration of medication as ordered. The findings will be immediately brought up to the Administrator for further action, if necessary. On 7/19/2023 the RNC (Regional Nurse Consultant) will start reviewing residents on Coumadin therapy and medications that require lab monitoring for dosage adjustments and therapeutic effectiveness for compliance to make sure Medication Orders, PT/INR and medication specific lab draws orders, and side effect monitoring orders are in EHR as ordered by physicians and completed, including medication administration and lab draws for four (4) weeks followed by monthly x 2 months. 7/19/2023 RNC/Designee will provide physical oversight at facility weekly x 4 weeks and then monthly x 2 months. The Director of Nursing/designee will monitor compliance by completing a random audit of 5 residents in the facility who are on Coumadin Therapy/medications that require lab monitoring for dosage adjustments and therapeutic effectiveness weekly for four (4) weeks. This will be initiated on 7/19/2023. Any identified concerns will be addressed immediately and if trends and patterns are identified, the facility will conduct an Ad-Hoc QAPI meeting to discuss if additional interventions are needed to ensure compliance for next 2 months. The Administrator will be responsible for ensuring this plan is completed on 7/19/2023. The RDO will provide oversight of Administrator to ensure that the items on the plan of removal are reviewed and completed. Monitoring of the Plan of Removal from 07/19/2023 - 07/21/2023 included the following: Reviewed the in-service, titled, PT/INR Q Monday, documentation, MARS/TARS, Orders and Abuse and Neglect dated 07/19/2023 given by [NAME] President of Clinical Services, RN that addressed Coumadin Therapy, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness, monitoring and assessing residents for changes in condition and following MD orders for medication dose and appropriate lab draws, and communication on lab results. Interview on 07/21/2023 at 4:00 PM with the DON confirmed she completed the in-service titled, Medication REeruiring Lag Monitoring, PT/INR, Coumadin/Warfarin flowsheet, Labs, Documentation, Seizure Precautions, MARS/TARS, Order, Observations, Contacting the Providers, Fire Safety, and Abuse and Neglect given by [NAME] President of Clinical Services, RN on 07/19/2023. Interview on 07/21/2023 at 4:38 PM with one of the two facility ADONs confirmed she completed the above referenced in-service given by [NAME] President of Clinical Services, RN on 07/19/2023. Interview on 07/21/2023 at 5:49 PM with the second of the two facility ADONs confirmed she completed the above reference in-service given by [NAME] President of Clinical Services, RN on 07/19/2023. Reviewed Resident #1's progress notes entered by the DON on 07/19/2023 that reflected Resident #1 was assessed for any changes in condition and if so, that the MD and Responsible party were notified. Confirmed Resident #1's Coumadin order and PT/INR lab work was reviewed with MD and orders updated for Resident #1 in EHR. Interviewed PRN LVN, ADON, facility LVN, and agency nurse who stated they participated, understood, and felt comfortable with the information given in the above referenced 07/19/2023 in-service given by the DON on Coumadin Therapy, physician orders and PT/INR lab draws tracking and communication, including medications that require lab monitoring for dosage adjustments and therapeutic effectiveness. Reviewed the Ad-Hoc QAPI meeting notes dated 07/19/2023, with the Medical Director, NHA (Nursing Home Administrator), Director of Nursing, Assistant Director of Nursing, RRC (Regional Reimbursement Consultant), and VPCS (Vice President of Clinical Services) to review the deficiency and the plan for removal of immediacy. The ADM and DON were informed the Immediate Jeopardy was removed on 07/21/2023 at 1:19 PM. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy identified and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.

Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (Resident #2) of 7 residents reviewed for accidents and hazards, in that: The facility failed to ensure exit doors in all halls were secured and locked to resident's safety. This deficient practice placed resident at risk for accidents, fall, skin tears, and visit to the hospital. The findings included: Record review of Resident #2 's undated face sheet revealed Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #2 had diagnoses of Alzheimer's disease, difficulty in walking, lack of coordination, weakness, insomnia, and muscle weakness. Record review of Resident #2's annual MDS, dated [DATE], revealed the resident had a BIMS score of 3, which indicated severe cognitive impairment. Record review of Resident #2's care plan dated 08/30/22, revealed Resident #2 continuously wanders throughout the facility throughout the day and at night in her wheelchair. Resident #2 was found outside in the parking lot on 08/27/22 at 2:46am laying on the ground. Record review of Resident #2's progress notes dated 08/27/22, revealed Resident #2 was last seen by staff at 1:10am. Resident #2 was sent to ER for further evaluation per doctor's order. Record review of the facility's provider investigation report dated 08/27/22 revealed Resident #2 was found outside the facility on 08/27/22 at 2:30 am laying on the floor with skin tear to left elbow and minor scrape to the face and resident complained of back pain. Report indicated head to toe assessment was conducted by a nurse and MD was notified and Resident #2 was sent to the emergency room . The provider's response to interventions was to change the door codes to the facility for extra safety, in-serviced staff on using the appropriate door to enter and exit the facility, and to keep doors locked. Observation on 08/30/22 at 11:29 a.m., Resident #2 was in bed sleeping. Observation on 09/2/22 at 1:50 p.m., Resident #2 was in her wheelchair, wheeling herself in the hallway. Observation on 09/02/22 at 1:25 p.m., the surveyor checked the delayed egress door at the end of the 600 hall and 700 hall and noted the doors were not locked and not alarmed. The Admin arrived at the 600-hall door and noted the door was not locked and not alarmed. The Admin stated someone had disengaged the door/alarm and did not reset the door which would lock the door and would turn the alarm on. The Admin showed the key switch that was located inside the nurses' station that would reset both the doors on 600 hall and 700 halls. The Admin stated will initiate an in-service immediately regarding keeping the doors locked at all times. Observation and interview on 09/02/22 at 1:36 p.m., the surveyor checked the delayed egress door at the end of the 300 hall and noted the doors were not locked and not alarmed. LVN- A and LVN-B were present at the nurses' station and stated someone did not reset the door. LVN-A and LVN-B each stated, and in-service was received on 08/28/22 regarding the doors. LVN-B stated, Some staff does not know how to reset the door and they just stop the sound from alarming and that is why the doors are not locked and alarmed. An interview on 09/02/22 at 2:07 p.m. the ADON stated, I don't know how she (Resident #2) got out of the facility, probably through the 600-hall door and she was found lying on the floor outside by one of the staff. The ADON stated the code to the door got changed. The ADON stated there was not any in-service conducted regarding making sure the exit doors were locked. The ADON stated there was an in-service done regarding using the front entrance door being used to enter and exit the building. The ADON stated changing the code to the door did not make any difference if anyone can go out if the doors are not locked and alarmed. The ADON stated she had just initiated an in-service on 09/02/22 to all staff regarding to make sure the doors are kept locked and alarmed and the use of reset button at the nurses' station. This in-service was not conducted as mentioned in the provider investigation report dated 08/27/22. An interview with the Maintenance Supervisor on 09/02/22 at 2:21 pm, he stated all doors are checked upon ground check at the start of the day. The Maintenance Supervisor stated he did not check the doors at the end of the hallway today (09/02/22) but most likely his assistant did. The Maintenance Supervisor stated he would have heard from his assistant if there were any problems during the ground check. The Maintenance Supervisor stated his assistant is unavailable at this time for an interview as he got pulled to do an assignment. The Maintenance Supervisor stated the codes to the doors was changed on 08/29/22 and there are two different codes, one to go outside and one to come inside the building. The Maintenance Supervisor stated the staff has the code to get out of the facility but does not have the code to get inside the facility and that all staff has to enter via the main entrance. An interview on 09/02/22 at 11:01 a.m., the Admin stated she does not know how R2 got outside of the facility. An interview on 09/02/22 at 3:01 p.m., the Admin stated Resident #2 has behavior of wheeling herself in her wheelchair inside the facility and just goes around in a circle. Admin said, She was never seen coming near the door. Admin stated the doors by the end of the halls, referred to 600 and 700 halls should have been locked and alarmed. Admin stated the doors needs to be reset by pressing a button at the nurses' station that will lock and alarm the doors. Record review of facility's policy Abuse Investigations dated February 2014 states: All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.

Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents reviewed for accidents. (Resident #4) CNA C failed to perform a proper transfer with Resident #4 which resulted in a fracture of her right ankle. Actual harm was determined to exist 10/24/2019. This was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could place residents at risk for injuries and a decreased quality of life. Findings include: Review of Resident #4's face sheet reflected that the resident was a [AGE] year-old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's most recent MDS, quarterly, dated 10/24/2019 reflected that the resident was an extensive assist with one staff member. Review of Resident #4's BIMS assessment reflected that the resident received a 10. A score of 10 can indicate that the resident had a moderate cognitive impairment. Review of Resident #4's progress note dated 10/27/2019 reflected that Medical Director was informed about right lower extremity swelling and redness and increased pain. Progress note reflected that a new order obtained for a venous ultrasound. Progress note further reflected the responsible party was notified. Review of Resident #4's physician orders [REDACTED]. Further review of the physician orders [REDACTED]. Review of Lower Extremity Venous Doppler dated 10/28/2019 reflected that the resident was negative for a D.V.T. to the right lower extremity. Review of right ankle x-ray dated 10/28/2019 reflected impression of acute distal tibial shaft fracture. In an interview on 11/12/2019 at 2:50 p.m., Resident #4 stated that she hurt her ankle when her feet got twisted and her ankle cracked. Resident #4 stated that she received pain medication and had received therapy. In an interview on 11/12/2019 at 1:17 p.m., CNA C stated that on 10/24/2019, at the end of the shift Resident #4 asked to be transferred back her bed from the wheelchair. CNA C stated when he completed the transfer Resident #4 said Oh my ankle. CNA C stated when he looked down he observed her feet where crossed. CNA C stated he proceed to complete the transfer and placed resident in bed. CNA C stated Resident #4 did not have marks on her legs. CNA C stated that this is a resident who had frequent complaints of pain, so he did not think of it being out of the ordinary and did not report it to the nurse. CNA C stated that after the resident was found to have had a fracture he received one on one training on transfers and when to report incidents to the nurse. In an interview on 11/12/2017 at 12:31 p.m., DON stated Resident #4 started to have complaints of pain and a doppler to rule out a blood clot and when that came back negative, an x-ray was ordered. DON stated that when the x-ray came back positive they began an investigation and found out that her complaints of pain started when CNA C conducted the transfer. DON stated CNA C did not report the incident to the nurse because Resident #4 did not have a mark on her. DON stated CNA C has been counseled that the expectations are to report to the nurse when residents have complaints of pain. In addition, Resident #4 has been reevaluated by therapy to adjust her transfer status. It was determined the above failures caused actual harm past non-compliance to Resident #4 from 10/24/2019. The facility took the following actions to correct the non-compliance on 10/30/2019. 1. On 10/29/2019 all nursing staff were in-serviced on transfer training/gait belts 2. On 10/29/2019 all nursing staff were in-serviced on assisting resident with transfers properly 3. On 10/30/2019 CNA C completed 1 on 1 Inservice on stop and watch tool, get help if resident is heavy or hard to transfer, taking time with resident care, and demonstrate use of gait belt and proficiency of transfers. Review of facility inservice documentation reflected on 10/29/2019 all staff attended inservices on transfer training/gait belts, and assisting residents with transfers properly. Review of facility inservice documentation reflected on 10/30/2019 CNA C received 1 on 1 training regarding the stop and watch tool, when to get help transferring a resident, taking time with resident care, and retrained on the use of gait belt and proficiency of transfers. Review of facility's policy, dated February 2014, titled Abuse Investigations reflected that all reports of resident abuse, neglect, injuries of unknown source shall be promptly and thoroughly investigated by facility management. Should an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.

Based on interview and record review the facility failed to ensure residents were free from neglect for three of eight residents (#1, 2 &3) whose records were reviewed for abuse/neglect. [NAME] The facility failed to prevent maggots from forming in Resident #1's wound by not accurately assessing the wound resulting in the resident being sent to the hospital. B. LVN A and the wound care nurse were observed not maintaining a clean field for wound care per standard nursing practice for Resident # 2 & 3 respectively. C. LVNs A and wound care nurse were observed not draping Resident # 2 & 3 wounds respectively while they left the treatment area. These failures resulted in an Immediate Jeopardy situation on 5/22/19. While the IJ was removed on 5/24/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure affected residents with wounds that became infected and could place other residents with wounds at risk for contamination, infection and even death. Findings include: [NAME] Review of Resident #1's face sheet reflected a [AGE] year-old male DOB 6/12/1965 with admission date of [DATE] and readmission of 5/19/2019. [DIAGNOSES REDACTED]. Review of Resident #1's significant change minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, meaning no impairment. Review of Resident #1's Care Plan 4/17/2019 reflected Resident had a surgical wound to left Above the Knee Amputation (AKA), and a surgical wound to right [MEDICAL CONDITION] (BKA), Resident has amputation to 1. Right leg below the knee 2. Left leg above the knee, is at risk for infection/pain/infiltration, resident is at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Review of Resident #1's discharge instructions details dated 4/2/4019 and 4/9/2019 from the wound care clinic reflected, should the Resident#1 experience any significant changes in his wound (s) or have questions regarding care instructions to call the wound clinic. If after regular business hours, call family doctor or local emergency room . Review of physician order [REDACTED].>Right BKA: cleanse wound with normal saline, pat dry, apply duoderm to periwound, then apply black or green foam then NPWT (wound vac) to wound continuously at 125mm/hg pressure. Change three times a week, once a day on tue/thus/sat. Review of Resident #1's Treatment Administration Records (TAR) for the month of (MONTH) reflected wound care was not done on Saturday, 4/27/2019 as ordered: Right BKA: cleanse wound with normal saline, pat dry, apply duoderm to periwound, then apply black or green foam then NPWT (wound vac) to wound continuously at 125mm/hg pressure. Change three times a week, once a day on tue/thus/sat. Review of Resident #1 progress notes dated 4/28/2019 at 6:34am reflected a temperature of 102.8F indicating fever or sign of infection. Review of Resident #1 progress notes dated 4/28/2019 at 7:46am reflected a temperature of 100.9F indicating fever or sign of infection. Review of Resident #1 progress notes dated 4/29/2019 at 1:15am reflected a temperature of 99.4F indicating low grade fever or sign of infection. Review of Resident #1 progress notes dated 4/29/2019 at 17:00pm reflected Resident #1 went to the ortho doctor, returned with no new orders. Review of Resident #1 progress notes dated 4/30/2019 at 5:01pm reflected Resident #1 had Altered Mental Status, not answering question appropriately and or following directions. Resident wound vac was intact and functional, no swelling or discoloration to right BK[NAME] Resident Above left knee was red in color warm to touch with non-[MEDICAL CONDITION] present, dressing was dry and intact. Resident required staff to assist in feeding and was transferred via wheel chair to the wound clinic by the facility's transportation. In an interview on 5/22/2019 at 11:42am, the wound care clinic staff stated Resident #1 was sick when he got to his wound doctor's appointment. He was confused and had fever and was sent to the hospital/ER. Review of Resident #1's most recent hospital report dated 4/30/2019 reflected upon admission Resident #1 had bilateral lower extremity amputation stump infections with maggots. On 5/1/2019-wound care removed an area of eschar on the left stump, which had couple of maggots within the superficial subcutaneous tissue. A debridement was performed, and a new dressing was placed. Continue with antibiotic and local wound care. Review or Resident #1 most recent hospital records dated 4/30/2019 through 5/19/2019 reflected he was diagnosed with [REDACTED]. UTI- with [DIAGNOSES REDACTED] pneumoniae ESBL in his urine, Fever, Pneumonia, Local Infection of the wound Review of Resident #1 hospital order reflected an order for [REDACTED]. Start date is 5/2/2019 and stop date 5/16/2019. Resident #1 hospital progress notes dated 5/11/2019 reflected the fever and wound infection was improved due to antibiotic therapy and wound care. In an interview on 5/21/2019 at 12:13pm, the ADON stated the surgeon (Resident #1 follows up with him regarding his recent amputation dated 3/30/2019) told her he had seen gnats in Resident #1's wound. She also stated the surgeon was concerned the facility had a problem with pests. She further stated, it seemed to her like the gnats being in Resident #1's wound would be an infection control and improper technique problem. She stated the facility had problems with gnats in the building about 2-3 weeks ago. In an interview on 5/21/2019 at 1:14pm, the wound care nurse stated Resident #1's wound vac is changed 3 times a week (tues/thurs/sat) and the rest of his wound dressings are changed daily and PRN. She also stated Resident #1's wound vac treatment was done on 4/27/19 and on 4/30/2019 he went to the wound clinic. She later said she did not work on 4/27/2019, the weekend supervisor was responsible for wound care on that day. In an interview on 5/21/2019 at 1:26pm, the weekend supervisor stated she is the wound care nurse for the weekend. She also stated she did not do the wound care for Resident #1 on Saturday, 4/27/2019 and she was not sure of why she didn't do it. She further stated she sometimes have to do some supervisory duties which prevents her from doing wound care. She later stated her standard procedure is to notify the floor nurses of what procedures were not performed. In an interview on 5/21/2019 at 3:07pm Resident #1's Responsible Party stated maggots were found in Resident #1's wound due to the gnat infestation in the facility. She also stated during one of Resident #1's wound doctor visits, gnats were found in the wound dressing and a week later maggots were found in the wound. In an interview on 5/21/2019 at 3:09pm, Resident #1 stated about 5 gnats were found in his left AKA wound. He also stated the facility was having problems with gnats in the building. He further stated, he doesn't like when the wound care nurse does his dressing changes because the wound is not covered well, and it leaks. In an interview on 5/22/2019 at 11:25am, when the ADON was asked what the facility did regarding the gnat's infestation in the building after they found out about the gnat being in Resident #1's wound? She stated she was made aware of gnats being in Resident #1 wound after he was transferred to the hospital on [DATE]. She also stated the gnats were treated. She later presented Action/Intervention for gnats in the Facility which was not dated. The in-service for the gnat's action/intervention was implemented and signed by staff on 5/21/2019 to 5/22/2019. *Room of infected resident cleaned/disinfected *Exterminations *Biohazard clean-up and extra pickup to two x monthly *wound care check-offs *Deep cleaning schedule established *Wounds evaluated for issues with infestations by staff nurses and weekly wound care physician-NO INFESTATIONNOTED *Roto Rooter cleaned sewer for less pest attractions *Re-educations to staff on what to do for any sightings pests *Re-education of nurses to drape open wounds during wound care so wound is not open if unattended *DAILY ROUNDS BY DEPT HEADS AND NURSES TO ASSURE NO ISSUES WITH PEST. In an interview on 5/21/2019 at 3:41pm the wound care doctor stated gnats were found in Resident # 1's dressing before. He also stated on the day the resident was transferred to the ER/hospital on [DATE] maggots were found in Resident #1's wound. He later stated Resident #1 was sick when he got to his wound care appointment. He further stated the maggots were due to the gnats and the cause of the wound infection. B. Review of Resident #2's face sheet reflected a [AGE] years old female DOB 02/07/1061 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's 14-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment. Review of Resident #2's Care Plan revealed the resident requires assistance with ADLs, and the goal was the wound will heal and infection will be resolved at the end of antibiotic therapy. Wound care observation on 5/22/2019 at 10:33am by LVN A, revealed LVN A removed the soiled dressing from Resident #2's left heel and put Resident # 2's left leg down on a clean surface now making it dirty. Resident #2 was unable to keep her left leg elevated. LVN A then went to the restroom in the resident's room to perform hand hygiene. LVN A donned clean gloves and cleaned Resident #2's wound with normal saline using gauze while holding the resident's leg with one hand. Each time LVN A turned around to get the gauze with normal saline, the resident's heel lowered back down to the dirty surface making the wound contaminated. LVN A then tried to apply the medication to the wound bed and opened the dressing packet but was unable to hold Resident #2's leg up. LVN A let go of Resident #2's left leg, back on the dirty surface, and stated she would start over. LVN A started the wound cleansing process over without changing the dirty pad under Resident # 2's left leg. Again, each time LVN A turned around to get the gauze with normal saline, the resident's heel was lowered back down on to the dirty surface making the wound contaminated. LVN A did not clean the wound again and applied the dressing to the wound. In an interview on 5/22/2019 at 10:47am LVN A stated she usually doesn't do wound care unless as needed or over the weekend if there is no wound care nurse. She also stated after cleaning the wound she should have put a clean pad under Resident # 2's left heel. She further stated letting the heel touch the dirty surface is an infection control problem, the wound was now contaminated. Review of facility's infection control log dated 5/5/2019 and 5/20/2019 reflected Resident #2 had a wound infection acquired in the facility. Review of Resident #3's face sheet reflected a [AGE] years old female DOB 09/14/1925 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 9 meaning moderately impaired. Review of Resident #3's Care Plan reflected resident's ulcer will heal without complication, requires assistance with ADLs, memory loss due to dementia. Observation of wound care conducted on 5/22/2019 at 11:07am for Resident #3 conducted by the wound care nurse she went into the room's bathroom which was on the other side of the curtain to wash her hands. The wound care nurse returned and put on gloves and tore open a clean dressing and dropped it onto the overbed table on the pad and labeled the dressing with date and initials with a sharpie, and then placed another pad under the resident's right foot. She removed the previous dressing from Resident 3's heel and placed the resident's leg on the pad now making it dirty. Resident # 3 was unable to keep her leg elevated to avoid contaminating the wound. The wound care nurse removed her gloves and went to the bathroom again to wash her hands and returned, put on gloves and cleansed the resident's heel wound with 2x2's that were soaked in normal saline. Before putting Resident #3's heel back down on the pad the wound care nurse did not change the pad that had been under the resident's heel thus contaminating the wound. At this point the wound care nurse was questioned about putting the resident's leg back on the dirty field and she stated that she had forgotten, she put a new pad under the resident's heel. The wound care nurse did not clean the wound after that and she applied medication and dressing. In an interview on 5/22/2019 at 11:33, when asked about maintaining clean or sterile technique during wound care, the wound care nurse stated she was following the facility's policy. In an interview on 5/22/2019 at 1:19pm the DON stated the pad was consider dirty after the uncleaned wounds were put on it. She also stated LVN A and wound care nurse should have changed the pad after it was dirty to prevent contamination to the Resident's wounds. She further stated the number of wounds with infection in the building is alarming and of concern. She later stated wound care is a problem and a major concern for her and she has identified problems with wounds and infection control. C. Review of Resident #2's face sheet reflected a [AGE] years old female DOB 02/07/1061 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's 14-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment. Review of Resident #2's Care Plan revealed the resident requires assistance with ADLs, and the goal was the wound will heal and infection will be resolved at the end of antibiotic therapy. During wound care observation on 5/22/2019 from 10:33am -10:47am, while LVN A was doing wound care on Resident # 2, it was observed that LVN A was leaving the area to wash her hands several times, the wound was not draped to prevent contamination, the supplies and resident were unattended and wouldn't have been unsupervised if the investigator had not been present. Review of Resident #3's face sheet reflected a [AGE] years old female DOB 09/14/1925 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 9 meaning moderately impaired. Review of Resident #3's Care Plan reflected resident's ulcer will heal without complication, requires assistance with ADLs, memory loss due to dementia. During wound care observation on 5/22/2019 from 11:03am -11:33am, while the wound care nurse was doing wound care on Resident # 3, it was observed that the wound care nurse was leaving the area to wash her hands several times, the wound was not draped to prevent contamination, the supplies and resident were unattended and would have been unsupervised if the investigator had not been present In an interview on 5/22/2019 at 11:33am, when asked about leaving the area to clean hands, the wound care nurse stated according to their hand hygiene policy, they were not allowed to use alcohol gel but had to wash their hands with soap and water during wound care. In an interview on 5/22/2019 at 1:19pm the DON stated the number of wounds with infection in the building is alarming and of concern. She later stated wound care is a problem and a major concern for her and she has identified problems with wounds and infection control. Review of the facility's pest control documentation reflected, on 3/19/2019 the administrator contacted her supervisor stating can you have pest control come out and spray for gnats? They are everywhere and quite annoying. Review of the facility's pest control documentation reflected first treatment regarding the gnats was dated 3/28/2019.The following was recommended: Kitchen ---debris or other material in drain causing blockage. Please remove debris to unblock drain and prevent attraction by pest. Dish area---standing water noted under dish machine. Please remove water high to prevent unsanitary conditions and moist environment that will become a pest attraction. Review of the facility's pest control documentation reflected the next treatment regarding the gnats was done on 4/25/2019. Review of facility's infection control log dated 4/28/2019 reflected Resident #1 had wound infection acquired in the facility. Review of the facility's wound care policy revised (MONTH) 2010 reflected the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Review of facility's 672 given by the MDS nurse on 5/21/2019 reflect 22 residents with pressure ulcers. Review of facility's last 3 months infection control logs reflected the following: --there was no wound infection identified in the month of March. --there were 4 wound infections in the month of (MONTH) with 2 of them being facility acquired. --there were 8 wound infections in the month of (MONTH) with 4 of them being facility acquired. Review of the facility's infection control policy revised (MONTH) 2012 reflected the purpose is to provide guidelines for general infection control while caring for residents. Review of the facility's wound care policy revised (MONTH) 2010 reflected the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The wound care Policy did not address draping the wound when unattended to prevent crossed contamination. ---Assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stages ---Report other information in accordance with facility policy and professional standards of practice. Review of the facility's dry/clean dressing policy revised (MONTH) reflected the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. ---Position the resident and adjust clothing to provide access to the affected area. Review of facility's wound care check list reflected --Position the resident comfortably and drape to expose only wound site. Place pad to protect bed if indicated and drape wound when washing hands. The Administrator was notified on 5/22/19 at 3:46 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template for plan of removal was given to the facility on [DATE] at 5:10 p.m. The following Plan of Removal was submitted by the administrator on 5/22/19 at 7:57p.m. The final Plan of Removal was accepted by the Survey Team on 5/22/2019 at 8:08pm. The facility's Plan of Removal was as follows: All nursing staff were immediately in serviced on 5/22/19 by the DON/designee regarding policy and procedures related to infection control and wound care. All nurses currently inhouse were reeducated on draping wounds, creating a clean field, and using hand sanitizer while doing wound care on 5/22/19 by the DON/designee. All nurses currently in house completed a return demonstration on wound care on 5/22/19. Nurses were contacted to immediately come into facility for in-service on wound care and to complete a return demonstration on wound care on 5/22/19. The staff that were not able to come to the facility will not be allowed to work until they complete the wound care in-service and return demonstration. All 19 residents with wounds were immediately assessed for a change of condition/infection in the wound bed starting at 6pm on 5/22/19 by checking for undermining slough, redness, warmth, drainage and odor. Any of the residents with wounds that have any sign or symptoms of infection the physician will be contacted, and new orders given. Contacted Medical Director for an immediate Quality Assurance Performance Improvement meeting regarding the IJ related to infection control related to wound care and he approved off on the plan of removal and had no further input. Administrator 5/22/19 7:48pm The Survey Team monitored the current plan of removal as follows: On 5/23/2019 at about 5:50pm, observation revealed the residents were either in their rooms, in the dining area, or in activity areas. No concerns were noted. Facility staff were actively engaged in resident care. No foul odors noted. On 5/23/2019 at 5:54pm Met with administrator who showed the documentation that had been done so far after the Immediate Jeopardy. She stated that they had held an ad hoc QA meeting with the Medical Director on 5/23/2019. She also stated all nurses had been retrained on infection control/wound care and had been skill-checked. She noted that they had started using hand sanitizer in the facility, and it was part of the new wound care process. She said that the skills checkoff list had not been updated, but that the use of hand sanitizer and the draping of the open wound field was now in the skills checkoff. She said that the staff could use hand sanitizer but that it was not a requirement. She also stated, upon questioning, that the QA/Q[NAME] committee would be tracking the wound infections more closely and that it was now an item on their QA agenda. On 5/23/2019 at 6:13pm in an interview with ADON C of the rehab unit, she stated the in-service had been helpful, and that all staff were now using hand sanitizer. She also stated that if the wound care nurse required assistance with respect to positioning the resident/protecting the wound field the wound care nurse would have an assistant (probably a CNA) during wound care. On 5/23/2019 at 6:18pm in an interview with Resident #4, he stated he was satisfied to a great extent with the services provided in the facility. On 5/23/2019 at 6:25pm in an interview with RN D, she stated she is the DON from another facility who had been brought in to assist with the training. She also stated she had personally assisted with the training of all the nurses at the facility, and that she felt they were competent to maintain appropriate infection control during wound care. On 5/23/2019 at 6:29pm in an interview with corporate clinical services director she stated the facility would be having ongoing infection control in-services. On 5/23/2019 at 6:35 in an interview with administrator, it was explained the IJ was not lifted at this time and she verbalized understanding. Exited facility. Record review of in-services completed by the facility and signed on wound care, hand hygiene/use of alcohol gel, wound dressing audit, signs and symptoms of wound infection dated 5/22/2019 at 8:00pm reflected 15 nurses were in-serviced on the new process. On 5/24/2019 at 10:00am review of the facility's immediacy plan dated 5/22/2019 revealed there was a skin swipe of the residents in the facility. On 5/24/2019 at 10:53am the Administrator was informed the Immediate Jeopardy was removed. However, the facility remained out of compliance at the level of actual harm with a scope identified as pattern due to the facility requiring additional time to train all staff and monitor their plan of removal. The Survey Team monitored the current plan of removal as follows: On 5/23/2019 at about 5:50pm, observation revealed the residents were either in their rooms, in the dining area, or in activity areas. No concerns were noted. Facility staff were actively engaged in resident care. No foul odors noted. On 5/23/2019 at 5:54pm Met with administrator who showed the documentation that had been done so far after the Immediate Jeopardy. She stated that they had held an ad hoc QA meeting with the Medical Director on 5/23/2019. She also stated all nurses had been retrained on infection control/wound care and had been skill-checked. She noted that they had started using hand sanitizer in the facility, and it was part of the new wound care process. She said draping of the open wound field was now in the skills checkoff. She said that the staff could use hand sanitizer but that it was not a requirement. She also stated, upon questioning, that the QA/Q[NAME] committee would be tracking the wound infections more closely and that it was now an item on their QA agenda. On 5/23/2019 at 6:13pm in an interview with ADON C of the rehab unit, she stated the in-service had been helpful, and that all staff were now using hand sanitizer. She also stated that if the wound care nurse required assistance with respect to positioning the resident/protecting the wound field the wound care nurse would have an assistant (probably a CNA) during wound care. On 5/23/2019 at 6:18pm in an interview with Resident #4, he stated he was satisfied to a great extent with the services provided in the facility. On 5/23/2019 at 6:25pm in an interview with RN D, she stated she is the DON from another facility who had been brought in to assist with the training. She also stated she had personally assisted with the training of all the nurses at the facility, and that she felt they were competent to maintain appropriate infection control during wound care. On 5/23/2019 at 6:29pm in an interview with corporate clinical services director she stated the facility would be having ongoing infection control in-services. On 5/23/2019 at 6:35pm in an interview with administrator, it was explained the IJ was not lifted at this time and she verbalized understanding. Exited facility. Record review of in-services completed by the facility and signed on wound care, hand hygiene/use of alcohol gel, wound dressing audit, signs and symptoms of wound infection dated 5/22/2019 at 8:00pm reflected 15 nurses were in-serviced on the new process. On 5/24/2019 at 10:00am review of the facility's immediacy plan dated 5/22/2019 revealed there was a skin swipe of the residents in the facility. On 5/24/2019 at 10:53am the Administrator was informed the Immediate Jeopardy was removed. However, the facility remained out of compliance at the level of actual harm with a scope identified as pattern due to the facility requiring additional time to train all staff and monitor their plan of removal.

Based on interview and record review, the facility failed to ensure three of eight residents reviewed for quality of care (Resident #1, 2, &3) received treatment and care for wounds in accordance with professional standards of practice in that: [NAME] The facility failed to prevent maggots from forming in Resident #1's wound by not accurately assessing the wound resulting in the resident being sent to the hospital with an infection. B. LVNs A and wound care nurse were observed not draping Resident # 2 & 3's wounds respectively while they left the treatment area. These failures resulted in an Immediate Jeopardy situation on 5/22/19. While the IJ was removed on 5/24/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure could affect all residents who require wound care treatment and place them at risk of loss of limb (s) and or death. Findings Include: [NAME] Review of Resident #1's face sheet reflected a [AGE] year-old male DOB 6/12/1965 with admission date of [DATE] and readmission of 5/19/2019. [DIAGNOSES REDACTED]. Review of Resident #1's significant change minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, meaning no impairment. Review of Resident #1's Care Plan 4/17/2019 reflected Resident had a surgical wound to left Above the Knee Amputation (AKA), and a surgical wound to right [MEDICAL CONDITION] (BKA), Resident has amputation to 1. Right leg below the knee 2. Left leg above the knee, is at risk for infection/pain/infiltration, resident is at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Review of Resident #1's discharge instructions details dated 4/2/4019 and 4/9/2019 from the wound care clinic reflected, should Resident#1 experience any significant changes in his wound (s) or have questions regarding care instructions to call the wound clinic. If after regular business hours, call family doctor or local emergency room . Review of physician order [REDACTED].>Right BKA: cleanse wound with normal saline, pat dry, apply duoderm to periwound, then apply black or green foam then NPWT (wound vac) to wound continuously at 125mm/hg pressure. Change three times a week, once a day on tue/thus/sat. Review of Resident #1's Treatment Administration Records (TAR) for the month of (MONTH) reflected wound care was not done on Saturday, 4/27/2019 as ordered: Right BKA: cleanse wound with normal saline, pat dry, apply duoderm to periwound, then apply black or green foam then NPWT (wound vac) to wound continuously at 125mm/hg pressure. Change three times a week, once a day on tue/thus/sat. Review of Resident #1's progress notes dated 4/28/2019 at 6:34am reflected a temperature of 102.8F indicating fever or sign of infection. Review of Resident #1's progress notes dated 4/28/2019 at 7:46am reflected a temperature of 100.9F indicating fever or sign of infection. Review of Resident #1's progress notes dated 4/29/2019 at 1:15am reflected a temperature of 99.4F indicating low grade fever or sign of infection. Review of Resident #1's progress notes dated 4/29/2019 at 5:00pm reflected Resident #1 went to the ortho doctor, returned with no new orders. Review of Resident #1 progress notes dated 4/30/2019 at 5:01pm reflected Resident #1 had Altered Mental Status, not answering question appropriately and or following directions. Resident's wound vac was intact and functional, no swelling or discoloration to right BK[NAME] Resident's left stump was red in color warm to touch with non-[MEDICAL CONDITION] present, dressing was dry and intact. Resident required staff to assist in feeding and was transferred via wheel chair to the wound clinic by the facility's transportation for routine wound care appointment. In an interview on 5/22/2019 at 11:42am, the wound care clinic staff stated Resident #1 was sick when he got to his wound doctor's appointment. He was confused and had fever and was sent to the hospital/ER. Review of Resident #1's most recent hospital report dated 4/30/2019 reflected upon admission Resident #1 had bilateral lower extremity amputation stump infections with maggots. On 5/1/2019-wound care removed an area of eschar on the left stump, which had couple of maggots within the superficial subcutaneous tissue. A debridement was performed, and a new dressing was placed. Continue with antibiotic and local wound care. Review or Resident #1's most recent hospital records dated 4/30/2019 through 5/19/2019 reflected he was diagnosed with [REDACTED]. UTI- with [DIAGNOSES REDACTED] pneumoniae ESBL in his urine, Fever, Pneumonia, Local Infection of the wound. Review of Resident #1's hospital order reflected an order for [REDACTED]. Start date is 5/2/2019 and stop date 5/16/2019. Review of Resident #1's hospital progress notes dated 5/11/2019 reflected the fever and wound infection was improved due to antibiotic therapy and wound care. In an interview on 5/21/2019 at 12:13pm, the ADON stated the surgeon (Resident #1 follows up with him regarding his recent amputation dated 3/30/2019) told her he had seen gnats in Resident #1's wound. She also stated the surgeon was concerned the facility had a problem with pests. She further stated, it seemed to her like the gnats being in Resident #1's wound would be an infection control and improper technique problem. She stated the facility had problems with gnats in the building about 2-3 weeks ago. In an interview on 5/21/2019 at 3:07pm Resident #1's Responsible Party stated maggots were found in Resident #1's wound due to the gnat infestation in the facility. She also stated during one of Resident #1's wound doctor visits, gnats were found in the wound dressing and a week later maggots were found in the wound. In an interview on 5/21/2019 at 3:09pm, Resident #1 stated about 5 gnats were found in his left AKA wound. He also stated the facility was having problems with gnats in the building. He further stated, he doesn't like when the wound care nurse does his dressing changes because the wound is not covered well, and it leaks. In an interview on 5/22/2019 at 11:25am, when the ADON was asked what the facility did regarding the gnat's infestation in the building after they found out about the gnat being in Resident #1's wound? She stated she was made aware of gnats being in Resident #1's wound after he was transferred to the hospital on [DATE]. She also stated the gnats were treated. She later presented Action/Intervention for gnats in the Facility which was not dated. The in-service for the gnats action/intervention was implemented and signed by staff on 5/21/2019 to 5/22/2019. *Room of infected resident cleaned/disinfected *Exterminations *Biohazard clean-up and extra pickup to two x monthly *wound care check-offs *Deep cleaning schedule established *Wounds evaluated for issues with infestations by staff nurses and weekly wound care physician-NO INFESTATIONNOTED *Roto Rooter cleaned sewer for less pest attractions *Re-educations to staff on what to do for any sightings pests *Re-education of nurses to drape open wounds during wound care so wound is not open if unattended *DAILY ROUNDS BY DEPT HEADS AND NURSES TO ASSURE NO ISSUES WITH PEST. In an interview on 5/21/2019 at 3:41pm the wound care doctor stated gnats were found in Resident # 1's dressing before. He also stated on the day the resident was transferred to the ER/hospital on [DATE] maggots were found in Resident #1's wound. He later stated Resident #1 was sick when he got to his wound care appointment. He further stated the maggots were due to the gnats and the cause of the wound infection. In an interview on 5/21/2019 at 1:14pm, the wound care nurse stated Resident #1's wound vac is changed 3 times a week (tues/thurs/sat) and the rest of his wound dressings are changed daily and PRN. She also stated Resident #1's wound vac treatment was done on 4/27/19 and on 4/30/2019 he went to the wound clinic. She later said she did not work on 4/27/2019, the weekend supervisor was responsible for wound care on that day. In an interview on 5/21/2019 at 1:26pm, the weekend supervisor stated she is the wound care nurse for the weekend. She also stated she did not do the wound care for Resident #1 on Saturday, 4/27/2019 and she was not sure of why she didn't do it. She further stated she sometimes have to do some supervisory duties which prevents her from doing wound care. She later stated her standard procedure is to notify the floor nurses of what procedures were not performed so they could do it. Review of facility's infection control log dated 4/28/2019 reflected Resident #1 had wound infection acquired in the facility. B. Review of Resident #2's face sheet reflected a [AGE] years old female DOB 02/07/1061 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's 14-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment. Review of Resident #2's Care Plan revealed the resident requires assistance with ADLs, and the goal was the wound will heal and infection will be resolved at the end of antibiotic therapy. During wound care observation on 5/22/2019 from 10:33am -10:47am, while LVN A was doing wound care on Resident # 2, it was observed that LVN A was leaving the area to wash her hands several times, the wound was not draped to prevent contamination, the supplies and resident were unattended and wouldn't have been unsupervised if the investigator had not been present In an interview on 5/22/2019 at 10:47am LVN A stated she usually doesn't do wound care unless as needed or over the weekend if there is no wound care nurse. She also stated after cleaning the wound she should have put a clean pad under Resident # 2's left heel. She further stated letting the heel touch the dirty surface is an infection control problem, the wound was now contaminated. Review of Resident #3's face sheet reflected a [AGE] years old female DOB 09/14/1925 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 9 meaning moderately impaired. Review of Resident #3's Care Plan reflected resident's ulcer will heal without complication, requires assistance with ADLs, memory loss due to dementia. During wound care observation on 5/22/2019 from 11:03am -11:33am, while the wound care nurse was doing wound care on Resident # 3, it was observed that the wound care nurse was leaving the area to wash her hands several times, the wound was not draped to prevent contamination, the supplies and resident were unattended and wouldn't have been unsupervised if the investigator had not been present. In an interview on 5/22/2019 at 11:33am, when asked about leaving the area to clean hands, the wound care nurse stated according to their hand hygiene policy, they were not allowed to use alcohol gel but had to wash their hands with soap and water during wound care. In an interview on 5/22/2019 at 1:19pm the DON stated wound care is a problem and a major concern for her and she has identified problems with wounds and infection control. Review of the facility's pest control documentation reflected, on 3/19/2019 the administrator contacted her supervisor stating can you have pest control come out and spray for gnats? They are everywhere and quite annoying. Review of the facility's pest control documentation reflected first treatment regarding the gnats was dated 3/28/2019.The following was recommended: Kitchen ---debris or other material in drain causing blockage. Please remove debris to unblock drain and prevent attraction by pest. Dish area---standing water noted under dish machine. Please remove water high to prevent unsanitary conditions and moist environment that will become a pest attraction. Review of the facility's pest control documentation reflected the next treatment regarding the gnats was done on 4/25/2019. Review of the facility's wound care policy revised (MONTH) 2010 reflected the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The wound care Policy did not address draping the wound when unattended to prevent crossed contamination. ---Assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stages ---Report other information in accordance with facility policy and professional standards of practice. The Administrator was notified on 5/22/19 at 3:46 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template for plan of removal was given to the facility on [DATE] at 5:10 p.m. The following Plan of Removal was submitted by the administrator on 5/22/19 at 7:57p.m. The final Plan of Removal was accepted by the Survey Team on 5/22/2019 at 8:08pm. The facility's Plan of Removal was as follows: All nursing staff were immediately in serviced on 5/22/19 by the DON/designee regarding policy and procedures related to infection control and wound care. All nurses currently inhouse were reeducated on draping wounds, creating a clean field, and using hand sanitizer while doing wound care on 5/22/19 by the DON/designee. All nurses currently in house completed a return demonstration on wound care on 5/22/19. Nurses were contacted to immediately come into facility for in-service on wound care and to complete a return demonstration on wound care on 5/22/19. The staff that were not able to come to the facility will not be allowed to work until they complete the wound care in-service and return demonstration. All 19 residents with wounds were immediately assessed for a change of condition/infection in the wound bed starting at 6pm on 5/22/19 by checking for undermining slough, redness, warmth, drainage and odor. Any of the residents with wounds that have any sign or symptoms of infection the physician will be contacted, and new orders given. Contacted Medical Director for an immediate Quality Assurance Performance Improvement meeting regarding the IJ related to infection control related to wound care and he approved off on the plan of removal and had no further input. Administrator 5/22/19 7:48pm The Survey Team monitored the current plan of removal as follows: On 5/23/2019 at about 5:50pm, observation revealed the residents were either in their rooms, in the dining area, or in activity areas. No concerns were noted. Facility staff were actively engaged in resident care. No foul odors noted. On 5/23/2019 at 5:54pm Met with administrator who showed the documentation that had been done so far after the Immediate Jeopardy. She stated that they had held an ad hoc QA meeting with the Medical Director on 5/23/2019. She also stated all nurses had been retrained on infection control/wound care and had been skill-checked. She noted that they had started using hand sanitizer in the facility, and it was part of the new wound care process. She said draping of the open wound field was now in the skills checkoff. She said that the staff could use hand sanitizer but that it was not a requirement. She also stated, upon questioning, that the QA/Q[NAME] committee would be tracking the wound infections more closely and that it was now an item on their QA agenda. On 5/23/2019 at 6:13pm in an interview with ADON C of the rehab unit, she stated the in-service had been helpful, and that all staff were now using hand sanitizer. She also stated that if the wound care nurse required assistance with respect to positioning the resident/protecting the wound field the wound care nurse would have an assistant (probably a CNA) during wound care. On 5/23/2019 at 6:18pm in an interview with Resident #4, he stated he was satisfied to a great extent with the services provided in the facility. On 5/23/2019 at 6:25pm in an interview with RN D, she stated she is the DON from another facility who had been brought in to assist with the training. She also stated she had personally assisted with the training of all the nurses at the facility, and that she felt they were competent to maintain appropriate infection control during wound care. On 5/23/2019 at 6:29pm in an interview with corporate clinical services director she stated the facility would be having ongoing infection control in-services. On 5/23/2019 at 6:35pm in an interview with administrator, it was explained the IJ was not lifted at this time and she verbalized understanding. Exited facility. Record review of in-services completed by the facility and signed on wound care, hand hygiene/use of alcohol gel, wound dressing audit, signs and symptoms of wound infection dated 5/22/2019 at 8:00pm reflected 15 nurses were in-serviced on the new process. On 5/24/2019 at 10:00am review of the facility's immediacy plan dated 5/22/2019 revealed there was a skin swipe of the residents in the facility. On 5/24/2019 at 10:53am the Administrator was informed the Immediate Jeopardy was removed. However, the facility remained out of compliance at the level of actual harm with a scope identified as pattern due to the facility requiring additional time to train all staff and monitor their plan of removal.

Based on observation, interview, and record review, it was determined the facility failed to maintain an Infection Control Program designed to help prevent the development and transmission of disease and infection for three (Residents #1,2 &3) of eight residents reviewed for infection control/wound infections. [NAME] The facility failed to prevent maggots from forming in Resident #1's wound by not accurately assessing the wound resulting in the resident being sent to the hospital. B. LVN A and the wound care nurse were observed not maintaining a clean field for wound care per standard nursing practice for Resident # 2 & 3 respectively. C. LVNs A and wound care nurse were observed not draping Resident # 2 & 3 wounds respectively while they left the treatment area. These failures resulted in an Immediate Jeopardy situation on 5/22/19. While the IJ was removed on 5/24/19, the facility remained out of compliance at a severity level of actual harm that is not immediate jeopardy with a scope of pattern due to the facility's need for monitoring the implementation of their corrective actions. This failure affected residents with wounds that became infected and could place other residents with wounds at risk for infection. Findings include: [NAME] Review of Resident #1's face sheet reflected a [AGE] year-old male DOB 6/12/1965 with admission date of [DATE] and readmission of 5/19/2019. [DIAGNOSES REDACTED]. Review of Resident #1's significant change minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, meaning no impairment. Review of Resident #1's Care Plan 4/17/2019 reflected Resident had a surgical wound to left Above the Knee Amputation (AKA), and a surgical wound to right [MEDICAL CONDITION] (BKA), Resident has amputation to 1. Right leg below the knee 2. Left leg above the knee, is at risk for infection/pain/infiltration, resident is at risk for frequent infections, pressure/venous/stasis ulcers, vision impairment, hyper/[DIAGNOSES REDACTED], [MEDICAL CONDITION], cognitive/physical impairment, slow healing process skin desensitized to pain or pressure related to diabetes mellitus. Review of Resident #1's discharge instructions details dated 4/2/4019 and 4/9/2019 from the wound care clinic reflected, should the Resident#1 experience any significant changes in his wound (s) or have questions regarding care instructions to call the wound clinic. If after regular business hours, call family doctor or local emergency room . Review of physician order [REDACTED].>Right BKA: cleanse wound with normal saline, pat dry, apply duoderm to periwound, then apply black or green foam then NPWT (wound vac) to wound continuously at 125mm/hg pressure. Change three times a week, once a day on tue/thus/sat. Review of Resident #1's Treatment Administration Records (TAR) for the month of (MONTH) reflected wound care was not done on Saturday, 4/27/2019 as ordered: Right BKA: cleanse wound with normal saline, pat dry, apply duoderm to periwound, then apply black or green foam then NPWT (wound vac) to wound continuously at 125mm/hg pressure. Change three times a week, once a day on tue/thus/sat. Review of Resident #1 progress notes dated 4/28/2019 at 6:34am reflected a temperature of 102.8F indicating fever or sign of infection. Review of Resident #1 progress notes dated 4/28/2019 at 7:46am reflected a temperature of 100.9F indicating fever or sign of infection. Review of Resident #1 progress notes dated 4/29/2019 at 1:15am reflected a temperature of 99.4F indicating low grade fever or sign of infection. Review of Resident #1 progress notes dated 4/29/2019 at 17:00pm reflected Resident #1 went to the ortho doctor, returned with no new orders. Review of Resident #1 progress notes dated 4/30/2019 at 5:01pm reflected Resident #1 had Altered Mental Status, not answering question appropriately and or following directions. Resident wound vac was intact and functional, no swelling or discoloration to right BK[NAME] Resident Above left knee was red in color warm to touch with non-[MEDICAL CONDITION] present, dressing was dry and intact. Resident required staff to assist in feeding and was transferred via wheel chair to the wound clinic by the facility's transportation. In an interview on 5/22/2019 at 11:42am, the wound care clinic staff stated Resident #1 was sick when he got to his wound doctor's appointment. He was confused and had fever and was sent to the hospital/ER. Review of Resident #1's most recent hospital report dated 4/30/2019 reflected upon admission Resident #1 had bilateral lower extremity amputation stump infections with maggots. On 5/1/2019-wound care removed an area of eschar on the left stump, which had couple of maggots within the superficial subcutaneous tissue. A debridement was performed, and a new dressing was placed. Continue with antibiotic and local wound care. Review or Resident #1 most recent hospital records dated 4/30/2019 through 5/19/2019 reflected he was diagnosed with [REDACTED]. UTI- with [DIAGNOSES REDACTED] pneumoniae ESBL in his urine, Fever, Pneumonia, Local Infection of the wound Review of Resident #1 hospital order reflected an order for [REDACTED]. Start date is 5/2/2019 and stop date 5/16/2019. Resident #1 hospital progress notes dated 5/11/2019 reflected the fever and wound infection was improved due to antibiotic therapy and wound care. In an interview on 5/21/2019 at 12:13pm, the ADON stated the surgeon (Resident #1 follows up with him regarding his recent amputation dated 3/30/2019) told her he had seen gnats in Resident #1's wound. She also stated the surgeon was concerned the facility had a problem with pests. She further stated, it seemed to her like the gnats being in Resident #1's wound would be an infection control and improper technique problem. She stated the facility had problems with gnats in the building about 2-3 weeks ago. In an interview on 5/21/2019 at 1:14pm, the wound care nurse stated Resident #1's wound vac is changed 3 times a week (tues/thurs/sat) and the rest of his wound dressings are changed daily and PRN. She also stated Resident #1's wound vac treatment was done on 4/27/19 and on 4/30/2019 he went to the wound clinic. She later said she did not work on 4/27/2019, the weekend supervisor was responsible for wound care on that day. In an interview on 5/21/2019 at 1:26pm, the weekend supervisor stated she is the wound care nurse for the weekend. She also stated she did not do the wound care for Resident #1 on Saturday, 4/27/2019 and she was not sure of why she didn't do it. She further stated she sometimes have to do some supervisory duties which prevents her from doing wound care. She later stated her standard procedure is to notify the floor nurses of what procedures were not performed. In an interview on 5/21/2019 at 3:07pm Resident #1's Responsible Party stated maggots were found in Resident #1's wound due to the gnat infestation in the facility. She also stated during one of Resident #1's wound doctor visits, gnats were found in the wound dressing and a week later maggots were found in the wound. In an interview on 5/21/2019 at 3:09pm, Resident #1 stated about 5 gnats were found in his left AKA wound. He also stated the facility was having problems with gnats in the building. He further stated, he doesn't like when the wound care nurse does his dressing changes because the wound is not covered well, and it leaks. In an interview on 5/22/2019 at 11:25am, when the ADON was asked what the facility did regarding the gnat's infestation in the building after they found out about the gnat being in Resident #1's wound? She stated she was made aware of gnats being in Resident #1 wound after he was transferred to the hospital on [DATE]. She also stated the gnats were treated. She later presented Action/Intervention for gnats in the Facility which was not dated. The in-service for the gnat's action/intervention was implemented and signed by staff on 5/21/2019 to 5/22/2019. *Room of infected resident cleaned/disinfected *Exterminations *Biohazard clean-up and extra pickup to two x monthly *wound care check-offs *Deep cleaning schedule established *Wounds evaluated for issues with infestations by staff nurses and weekly wound care physician-NO INFESTATIONNOTED *Roto Rooter cleaned sewer for less pest attractions *Re-educations to staff on what to do for any sightings pests *Re-education of nurses to drape open wounds during wound care so wound is not open if unattended *DAILY ROUNDS BY DEPT HEADS AND NURSES TO ASSURE NO ISSUES WITH PEST. In an interview on 5/21/2019 at 3:41pm the wound care doctor stated gnats were found in Resident # 1's dressing before. He also stated on the day the resident was transferred to the ER/hospital on [DATE] maggots were found in Resident #1's wound. He later stated Resident #1 was sick when he got to his wound care appointment. He further stated the maggots were due to the gnats and the cause of the wound infection. B. Review of Resident #2's face sheet reflected a [AGE] years old female DOB 02/07/1061 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's 14-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment. Review of Resident #2's Care Plan revealed the resident requires assistance with ADLs, and the goal was the wound will heal and infection will be resolved at the end of antibiotic therapy. Wound care observation on 5/22/2019 at 10:33am by LVN A, revealed LVN A removed the soiled dressing from Resident #2's left heel and put Resident # 2's left leg down on a clean surface now making it dirty. Resident #2 was unable to keep her left leg elevated. LVN A then went to the restroom in the resident's room to perform hand hygiene. LVN A donned clean gloves and cleaned Resident #2's wound with normal saline using gauze while holding the resident's leg with one hand. Each time LVN A turned around to get the gauze with normal saline, the resident's heel lowered back down to the dirty surface making the wound contaminated. LVN A then tried to apply the medication to the wound bed and opened the dressing packet but was unable to hold Resident #2's leg up. LVN A let go of Resident #2's left leg, back on the dirty surface, and stated she would start over. LVN A started the wound cleansing process over without changing the dirty pad under Resident # 2's left leg. Again, each time LVN A turned around to get the gauze with normal saline, the resident's heel was lowered back down on to the dirty surface making the wound contaminated. LVN A did not clean the wound again and applied the dressing to the wound. In an interview on 5/22/2019 at 10:47am LVN A stated she usually doesn't do wound care unless as needed or over the weekend if there is no wound care nurse. She also stated after cleaning the wound she should have put a clean pad under Resident # 2's left heel. She further stated letting the heel touch the dirty surface is an infection control problem, the wound was now contaminated. Review of facility's infection control log dated 5/5/2019 and 5/20/2019 reflected Resident #2 had a wound infection acquired in the facility. Review of Resident #3's face sheet reflected a [AGE] years old female DOB 09/14/1925 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 9 meaning moderately impaired. Review of Resident #3's Care Plan reflected resident's ulcer will heal without complication, requires assistance with ADLs, memory loss due to dementia. Observation of wound care conducted on 5/22/2019 at 11:07am for Resident #3 conducted by the wound care nurse she went into the room's bathroom which was on the other side of the curtain to wash her hands. The wound care nurse returned and put on gloves and tore open a clean dressing and dropped it onto the overbed table on the pad and labeled the dressing with date and initials with a sharpie, and then placed another pad under the resident's right foot. She removed the previous dressing from Resident 3's heel and placed the resident's leg on the pad now making it dirty. Resident # 3 was unable to keep her leg elevated to avoid contaminating the wound. The wound care nurse removed her gloves and went to the bathroom again to wash her hands and returned, put on gloves and cleansed the resident's heel wound with 2x2's that were soaked in normal saline. Before putting Resident #3's heel back down on the pad the wound care nurse did not change the pad that had been under the resident's heel thus contaminating the wound. At this point the wound care nurse was questioned about putting the resident's leg back on the dirty field and she stated that she had forgotten, she put a new pad under the resident's heel. The wound care nurse did not clean the wound after that and she applied medication and dressing. In an interview on 5/22/2019 at 11:33, when asked about maintaining clean or sterile technique during wound care, the wound care nurse stated she was following the facility's policy. In an interview on 5/22/2019 at 1:19pm the DON stated the pad was consider dirty after the uncleaned wounds were put on it. She also stated LVN A and wound care nurse should have changed the pad after it was dirty to prevent contamination to the Resident's wounds. She further stated the number of wounds with infection in the building is alarming and of concern. She later stated wound care is a problem and a major concern for her and she has identified problems with wounds and infection control. C. Review of Resident #2's face sheet reflected a [AGE] years old female DOB 02/07/1061 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's 14-day minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 15, indicating no impairment. Review of Resident #2's Care Plan revealed the resident requires assistance with ADLs, and the goal was the wound will heal and infection will be resolved at the end of antibiotic therapy. During wound care observation on 5/22/2019 from 10:33am -10:47am, while LVN A was doing wound care on Resident # 2, it was observed that LVN A was leaving the area to wash her hands several times, the wound was not draped to prevent contamination, the supplies and resident were unattended and wouldn't have been unsupervised if the investigator had not been present. Review of Resident #3's face sheet reflected a [AGE] years old female DOB 09/14/1925 with admission date of [DATE]. [DIAGNOSES REDACTED]. Review of Resident #3's quarterly minimum data set (MDS) assessment dated [DATE] reflected a brief interview for mental status (BIMS) score of 9 meaning moderately impaired. Review of Resident #3's Care Plan reflected resident's ulcer will heal without complication, requires assistance with ADLs, memory loss due to dementia. During wound care observation on 5/22/2019 from 11:03am -11:33am, while the wound care nurse was doing wound care on Resident # 3, it was observed that the wound care nurse was leaving the area to wash her hands several times, the wound was not draped to prevent contamination, the supplies and resident were unattended and would have been unsupervised if the investigator had not been present In an interview on 5/22/2019 at 11:33am, when asked about leaving the area to clean hands, the wound care nurse stated according to their hand hygiene policy, they were not allowed to use alcohol gel but had to wash their hands with soap and water during wound care. In an interview on 5/22/2019 at 1:19pm the DON stated the number of wounds with infection in the building is alarming and of concern. She later stated wound care is a problem and a major concern for her and she has identified problems with wounds and infection control. Review of the facility's pest control documentation reflected, on 3/19/2019 the administrator contacted her supervisor stating can you have pest control come out and spray for gnats? They are everywhere and quite annoying. Review of the facility's pest control documentation reflected first treatment regarding the gnats was dated 3/28/2019.The following was recommended: Kitchen ---debris or other material in drain causing blockage. Please remove debris to unblock drain and prevent attraction by pest. Dish area---standing water noted under dish machine. Please remove water high to prevent unsanitary conditions and moist environment that will become a pest attraction. Review of the facility's pest control documentation reflected the next treatment regarding the gnats was done on 4/25/2019. Review of facility's infection control log dated 4/28/2019 reflected Resident #1 had wound infection acquired in the facility. Review of the facility's wound care policy revised (MONTH) 2010 reflected the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Review of facility's 672 given by the MDS nurse on 5/21/2019 reflect 22 residents with pressure ulcers. Review of facility's last 3 months infection control logs reflected the following: --there was no wound infection identified in the month of March. --there were 4 wound infections in the month of (MONTH) with 2 of them being facility acquired. --there were 8 wound infections in the month of (MONTH) with 4 of them being facility acquired. Review of the facility's infection control policy revised (MONTH) 2012 reflected the purpose is to provide guidelines for general infection control while caring for residents. Review of the facility's wound care policy revised (MONTH) 2010 reflected the purpose of this procedure is to provide guidelines for the care of wounds to promote healing. The wound care Policy did not address draping the wound when unattended to prevent crossed contamination. ---Assess the wound and surrounding skin for [MEDICAL CONDITION], redness, drainage, tissue healing progress and wound stages ---Report other information in accordance with facility policy and professional standards of practice. Review of the facility's dry/clean dressing policy revised (MONTH) reflected the purpose of this procedure is to provide guidelines for the application of dry, clean dressings. ---Position the resident and adjust clothing to provide access to the affected area. Review of facility's wound care check list reflected --Position the resident comfortably and drape to expose only wound site. Place pad to protect bed if indicated and drape wound when washing hands. The Administrator was notified on 5/22/19 at 3:46 p.m. an Immediate Jeopardy situation had been identified due to the above failures. The IJ template for plan of removal was given to the facility on [DATE] at 5:10 p.m. The following Plan of Removal was submitted by the administrator on 5/22/19 at 7:57p.m. The final Plan of Removal was accepted by the Survey Team on 5/22/2019 at 8:08pm. The facility's Plan of Removal was as follows: All nursing staff were immediately in serviced on 5/22/19 by the DON/designee regarding policy and procedures related to infection control and wound care. All nurses currently inhouse were reeducated on draping wounds, creating a clean field, and using hand sanitizer while doing wound care on 5/22/19 by the DON/designee. All nurses currently in house completed a return demonstration on wound care on 5/22/19. Nurses were contacted to immediately come into facility for in-service on wound care and to complete a return demonstration on wound care on 5/22/19. The staff that were not able to come to the facility will not be allowed to work until they complete the wound care in-service and return demonstration. All 19 residents with wounds were immediately assessed for a change of condition/infection in the wound bed starting at 6pm on 5/22/19 by checking for undermining slough, redness, warmth, drainage and odor. Any of the residents with wounds that have any sign or symptoms of infection the physician will be contacted, and new orders given. Contacted Medical Director for an immediate Quality Assurance Performance Improvement meeting regarding the IJ related to infection control related to wound care and he approved off on the plan of removal and had no further input. Administrator 5/22/19 7:48pm The Survey Team monitored the current plan of removal as follows: On 5/23/2019 at about 5:50pm, observation revealed the residents were either in their rooms, in the dining area, or in activity areas. No concerns were noted. Facility staff were actively engaged in resident care. No foul odors noted. On 5/23/2019 at 5:54pm Met with administrator who showed the documentation that had been done so far after the Immediate Jeopardy. She stated that they had held an ad hoc QA meeting with the Medical Director on 5/23/2019. She also stated all nurses had been retrained on infection control/wound care and had been skill-checked. She noted that they had started using hand sanitizer in the facility, and it was part of the new wound care process. She said that the skills checkoff list had not been updated, but that the use of hand sanitizer and the draping of the open wound field was now in the skills checkoff. She said that the staff could use hand sanitizer but that it was not a requirement. She also stated, upon questioning, that the QA/Q[NAME] committee would be tracking the wound infections more closely and that it was now an item on their QA agenda. On 5/23/2019 at 6:13pm in an interview with ADON C of the rehab unit, she stated the in-service had been helpful, and that all staff were now using hand sanitizer. She also stated that if the wound care nurse required assistance with respect to positioning the resident/protecting the wound field the wound care nurse would have an assistant (probably a CNA) during wound care. On 5/23/2019 at 6:18pm in an interview with Resident #4, he stated he was satisfied to a great extent with the services provided in the facility. On 5/23/2019 at 6:25pm in an interview with RN D, she stated she is the DON from another facility who had been brought in to assist with the training. She also stated she had personally assisted with the training of all the nurses at the facility, and that she felt they were competent to maintain appropriate infection control during wound care. On 5/23/2019 at 6:29pm in an interview with corporate clinical services director she stated the facility would be having ongoing infection control in-services. On 5/23/2019 at 6:35 in an interview with administrator, it was explained the IJ was not lifted at this time and she verbalized understanding. Exited facility. Record review of in-services completed by the facility and signed on wound care, hand hygiene/use of alcohol gel, wound dressing audit, signs and symptoms of wound infection dated 5/22/2019 at 8:00pm reflected 15 nurses were in-serviced on the new process. On 5/24/2019 at 10:00am review of the facility's immediacy plan dated 5/22/2019 revealed there was a skin swipe of the residents in the facility. On 5/24/2019 at 10:53am the Administrator was informed the Immediate Jeopardy was removed. However, the facility remained out of compliance at the level of actual harm with a scope identified as pattern due to the facility requiring additional time to train all staff and monitor their plan of removal.

Based on observation, interview and record review, the facility failed to ensure residents with pressure ulcers were treated with professional standards of quality for two of two residents reviewed for pressure ulcer care (Resident #1 and #4). [NAME] The facility failed to follow professional standards when Resident #1's did not receive pain medication prior to her wound care, her sacral ulcer was not cleansed or packed during treatment and Resident #1's pressure ulcer had documentation it had progressed to Stage III with slough and odor. B. The facility failed to follow professional standards when Resident #4's [MEDICATION NAME] ointment and medicinal dressing were not placed directly and only in the ulcer bed when Resident #4 had a stage IV pressure ulcer on his lateral foot. He was not wearing a heel protector as ordered by physcian. These failures to provide ulcer care using professional standards could lead to declines in ulcers, infection,[MEDICAL CONDITION], and death for residents who have or develop ulcers. Findings included: [NAME] Review of Resident #1's Face sheet reflected she was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 12 which indicated she had moderate cognitive impairment, no behaviors, and needed extensive assistance of two people for bed mobility and transferring. She was frequently incontinent. She was coded to have one Stage III ulcer. Review of Resident #1's care plan reflected; Problem start date 04/22/2018 Pressure ulcer Stage III to coccyx. Goal: Pressure ulcer will show signs of healing and remain free of infection through next review. Interventions included; Administer treatments as ordered and monitor for effectiveness. Provide supplemental protein, amino acids, vitamins and minerals as ordered to promote wound healing. Provide with pressure relieving cushion while up in wheelchair. Pressure relieving mattress. An additional care plan reflected Resident #1 was at risk for pain in her lower back and lower extremities. Review of Resident #1's Skin Treatment flow sheet dated (MONTH) 2019 reflected an order dated 02/23/2019 for Sacrum - Cleanse with normal saline, pat dry, apply santyl, calcium alginate and foam or dry protective dressing daily and as needed. Review of Resident #1's Physician order [REDACTED]. 07/06/2018 for Multi-vitamin one daily for pressure ulcer of sacral region, stage II and vitamin C 500 mg one daily for pressure ulcer of sacral region, stage II. 08/10/2018 for supplemental nutrition; Medpass 60 ml (two ounces) three times a day for wound healing. 02/21/2019 reflected Santyl ointment, dime thick; topical. [DIAGNOSES REDACTED]. 2/23/2019 reflected; Sacrum - Cleanse with normal saline, pat dry, apply santyl, calcium alginate and foam or dry protective dressing daily and as needed. Additional orders included; heel protectors to off load pressure, float heels in bed, add fortified foods to all meals, house shake daily on dinner tray and gel cushion to wheelchair. Review of Resident #1's (MONTH) 2019 Medication Flowsheet reflected Resident #1 received [MEDICATION NAME] 300 mg one tablet three times a day for general pain routinely. Further review reflected Resident #1 did not receive any prn pain medication on (MONTH) 1st which indicates resident did not receive any additional pain medicine prior to wound treatment on 3/1/19. On (MONTH) 2nd Resident #1 received one Tylenol with [MEDICATION NAME] #3 for pain as needed one time and ADON D's initials were on the flowsheet. This medication was administered after wound care as noted in observation below. Review of Resident #1's Wound Evaluation and Management Summary reports by the wound physician that visited weekly reflected: sacral pressure ulcer stage III (three). 02/01/2019 Measurements: 1.2 x 0.3 x 1.4 cm with 2.0 cm of undermining (tunneling) at 12 o'clock (towards her head). Duration of treatment greater than 217 days. Exudate; moderate serous, slough (dead) - 30%, granulation - 70%, Deteriorated. Wound cleansed with normal saline, anesthetized, surgically excised .11 cm squared of devitalized tissue including slough, biofilm and non-viable subcutaneous fat .to a depth of 1.4 cm . Treatment; continue with collagen powder, calcium alginate and foam with boarder dressing. 02/07/2019 Measurements; 0.9 x 0.3 x 1.4 cm undermining 2.0 cm at 12 o'clock. Exudate; moderate serous, 100% granulation (healthy tissue). Improved. Treatment; collagen powder, calcium alginate and foam with boarder dressing once daily. 02/14/19 Measurements; 0.7 x 0.2 x 1.4 cm undermining 2.0 cm at 12 o'clock. Exudate; heavy serous, 100% granulation tissue. Improved. Treatment; collagen powder, calcium alginate and foam with boarder dressing once daily. 02/21/19 Measurements; 1.5 x 1.2 x 1.6 cm, undermining 2.0 cm at 12 o'clock. Exudate; moderate serous, 70% granulation tissue and 30% slough. Deteriorated. Excised (cut out) 0.54 cm of devitalized tissue. Bio film and non-viable subcutaneous fat at a depth of 1.8 cm. Debridement/removed thick, adherent eschar (dead), necrotic (dead) tissue and established margins of vital tissue (living). Treatment; (new) Santyl, calcium alginate and foam with boarder dressing once daily. 02/28/19 Measurements; 1.5 x 1.2 x 2.0 cm, undermining 2.0 cm at 12 o'clock. Exudate; moderate serous, 50% granulation and 50% slough. Deteriorated. Excised (cut out) 0.90 cm of devitalized tissue. Bio film and non-viable sub cutaneous fat at a depth of 2.0 cm. Debridement/removed thick, adherent eschar and devitalized tissue (dead) and necrotic tissue to re-establish the margins of vital tissue. In an observation/interview on 03/02/2019 at 12:35 LVN [NAME] brought supplies to provide ulcer care to the bed side and laid them on the bed directly beside Resident #1. While LVN [NAME] washed her hands, Resident #1 made sad sounds and stated she was in pain. LVN [NAME] came back to the room and told Resident #1 to roll over on her side. Resident made a sad sound saying, It hurts. LVN [NAME] stated she would be as gentle as she could be but did not offer any pain medication. LVN [NAME] rolled Resident #1 over on her right side and the daughter held her over. When LVN [NAME] lowered Resident #1's brief, surveyor observed tan/brown wound drainage on the brief the size of a half dollar and an approximately 3.0 cm dark hole in Resident #1's sacrum. There was an approximately 0.33 cm wide and 1.0 cm long flap of green dead tissue protruding from the edge of the ulcer on the right side. Immediately around the pressure ulcer opening, the epidermis (top layer of skin) was macerated (white with moisture) and was sloughing off in places revealing raw skin. There was no dressing in place. Resident #1's daughter stated, I see why she is complaining about pain now. Oh, the smell is putrid. LVN [NAME] donned gloves and took 4 x 4s off the bed and squirted normal saline on gauze and wiped the skin surrounding the opening three times with three different gauze 4 x 4s. Then with the same contaminated gloves on, she put her finger in the medicine cup of ointment and rubbed santyl only on the macerated and the healthy skin around the ulcer opening. LVN [NAME] did not cleanse or treat the pressure ulcer, only the surrounding skin. LVN [NAME] changed gloves, (did not sanitize or wash her hands) and opened calcium alginate and placed the rectangular square on the macerated and healthy skin surrounding the opening and not in the ulcer bed. After LVN [NAME] opened the foam dressing cover and was about to place it on the skin, surveyor stopped LVN [NAME] and had ADON D look at the manner of the application of the ointment and dressing. Surveyor told ADON D LVN [NAME] had washed the surrounding skin, put santyl ointment on the surrounding skin and placed the calcium alginate on the surrounding skin. ADON D looked at the santyl on the surrounding skin, the calcium alginate rectangle on the skin (covering over the open ulceration) and stated it was fine and asked to see the ulcer. LVN [NAME] raised her calcium alginate rectangle to reveal the open hole with no packing and the ADON D stated, Oh, ok. Go ahead. LVN [NAME] lowered the calcium alginate back on the surrounding skin and put the foam border dressing over the santyl and calcium alginate. The daughter stated, The smell will knock you out. Resident #1 moaned and ADON D stated, I will get her something for pain and left the room. LVN [NAME] wrote the date on the dressing. Took her gloves off, opened the door and got more gloves and said she would have the aide come change the brief (because it had wound drainage on it that was high odor). In an observation on 03/02/2019 at 12:49 PM ADON D brought Resident #1 a Tylenol #3 pain tablet and administered it (after LVN [NAME] performed ulcer care). In an interview on 03/02/2019 at 3:10 PM the ADON D stated Resident #1 had a significant ulceration. The DON stated, I have not seen Resident #1's ulceration yet but I heard it is getting better. B. Review of Resident #4's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] reflected a BIMS score of nine which indicated he had moderate cognitive impairment. He had no behaviors, and required extensive assistance of two people for transferring, and bed mobility. Section I, Active Diagnoses, did not reflect he had a pressure ulcer. Section M, Skin Conditions, reflected he had a stage four pressure ulcer. Review of Resident #4's Care plan dated 01/08/2019 reflected; Resident is at risk for pressure ulcer due to impaired mobility. Goal; Intact skin without evidence of redness, irritation, maceration, or open areas. Approach; skin assessment and inspections weekly and turn and reposition every two hours and as needed. The care plan did not reflect Resident #4 had any pressure ulcers. Review of Resident #4's Physician order [REDACTED]. 11/27/18; Med pass 60 ml (two ounces) twice a day [DIAGNOSES REDACTED]. 01/25/2019 Right plantar/lateral foot - cleanse with normal saline, pat dry, apply santyl, calcium alginate and cover with dry protective dressing daily. 02/19/19 Santyl ointment, dime thick topical, 1.7 x 1.5 [DIAGNOSES REDACTED]. Review of Resident #4's Treatment Administration record dated (MONTH) 2019 reflected an order for [REDACTED]. Review of Resident #4's Wound Evaluation and Management Summary reports by the wound physician that visited weekly reflected: 02/28/2019 - Stage IV (four) pressure wound of the right, distal, lateral foot. 1.7 x 1.5 x not measurable. Surface area 2.55 cm squared. Duration: greater than 105 days. Exudate: Moderate Serous, thick adherent devitalized necrotic tissue 5%, Granulation tissue 95%, Improved. After anesthetize, 0.13 cm squared of devitalized tissue and necrotic muscle . were removed at a depth of 0.6 cm and healthy bleeding tissue was observed. (On 02/28/19 after the wound doctor debrided the ulcer, it was 0.6 cm deep and red granulating tissue only). In an observation on 03/02/2019 at 3:47 PM Resident #4 was in a recliner in his room with no pressure relief devices on. His right heel was flat on the recliner foot rest. The DON cued LVN [NAME] to get a disposable pad to provide a clean field before she started wound care on the recliner foot rest. LVN [NAME] provided wound care and started by placing Resident #4's socked foot in the middle of the clean field. LVN [NAME] removed the sock and the dressing to reveal Resident #4's ulceration to his lateral right foot at the base of the fifth toe. After LVN [NAME] removed the square piece of calcium alginate dressing that was only partially in the wound bed, the ulcer was observed to be approximately 5 mm deep. The bed of the ulcer was approximately 80% covered with green slough and therefore it was not stageable. (All slough had previously been removed on 02/28/2019 therefore the ulcer bed had significantly declined.) The ulcer was surrounded almost entirely by white, wet, macerated skin due to the calcium alginate treatment (which gathers moisture) was cut in a square and was not just in the wound bed but also on most of the surrounding skin. The DON told LVN [NAME] to get out some sanitizer for her hands and also to sanitize the scissors she had removed from her fanny pack during wound care. LVN [NAME] used her gloved finger to apply santyl ointment in and all around the ulcer on the surrounding skin. She placed a rectangular calcium alginate across the entire opening and on the surrounding skin all around the ulcer. The calcium alginate was across the wound bed, (like a roof) and not touching the wound bed. The DON did not redirect LVN [NAME] to cut the calcium alginate to fit in the wound bed. LVN [NAME] wrapped Resident #4's foot with gauze and taped it. In an interview on 03/02/2019 at 3:47 PM the DON stated, For pressure relief, he has something propping his feet off his bed. This is the first time I have seen him in that chair. It looks like we will need to get something for him for this chair for pressure relief. In an interview on 03/02/2019 at 4:15 PM LVN [NAME] stated she did not know what action santyl had on an ulcer, she stated she did not know what calcium alginate was for or that it was supposed to be directly touching the ulcer bed only. LVN [NAME] stated she saw that Resident #4's skin surrounding the ulcer was white with moisture damage, but she did not realize the ointment and calcium alginate would cause the moisture damage. LVN [NAME] stated the order said to put the santyl on topically. She stated she did not pack the ulcer for Resident #1 because she did not have an order to pack the ulcer. LVN [NAME] stated she didn't know the santyl and calcium alginate cannot heal the ulcer if applied on the surrounding skin only (Resident #1). In an interview on 03/02/2019 at 4:25 PM the DON stated the santyl is supposed to only be put in the ulcer and the calcium alginate is only supposed to be put in the ulcer. She stated Resident #4's ulcer was macerated with moisture and should not be. She stated Resident #1's ulcer should have been packed and the orders for both resident's ulcer treatments should have been worded plainly that the santyl and calcium alginate were to be placed in the ulcer bed. The DON stated she had to cue LVN [NAME] during ulcer care for infection control, but the wound care products representative had told the nursing staff they could use a gloved finger to apply ointments to wounds and it wouldn't hurt to put the ointment on the healthy surrounding skin also. In an interview on 03/02/2019 at 5:20 PM the Medical Director he expected the nurses to follow the MD orders, but they may be following them in a simplistic manner at times. The Medical Director stated; Wound care is a multi-focal process (clear physician's orders [REDACTED]. When we do wound care for a wound that is of depth (at the clinic), we irrigate the wounds inner areas to cleanse them. We pack the inner wound for a while at least (place the prescribed healing agent in the wound bed). We use less and less of packing as it heals; three inches (of packing materials) then two inches and so on, so as not to cause pressure but to cleanse the inner wound. In an interview on 03/06/2019 at 1:22 PM the Wound Care MD stated he evaluated, measured and performed the treatment on the ulcers for Residents #1 and #4 every week. The Wound Care MD stated when he administered medications to wound/ulcer beds he usually used a cotton swab to apply the ointment and the calcium alginate was cut to fit on the ulcer bed or it was tucked inside of an ulceration. He stated it was possible that ulcer treatment being delivered in the manner the surveyor observed could play a role in the deterioration of the wounds but that both residents had multiple [DIAGNOSES REDACTED]. He further stated he usually had his patients receive pain medicine before he delivered care. He stated putting the supplies on the bed could lead to cross contamination and putting a sock in the middle of the clean field voided the clean field. He further stated he thought that the nurses at the facility were aware of the basic principles of wound care. Review of the website: https://www.santyl.com/hcp/dosing on 03/04/2019 at 4:41 PM reflected; Indication - Santyl Ointment is indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas. Important Safety Information: Use of Santyl ointment should be terminated when debridement is complete and granulation tissue is well established. How to apply: Apply SANTYL Ointment out to the edges of the wound. Take care not to extend beyond the wound surface although it does not harm healthy tissue. A video on the website reflected the ointment was to be applied with a wooden applicator within the wound bed only. Occasional slight transient [DIAGNOSES REDACTED] has been noted in surrounding tissue when applied outside the wound. Review of the website; https://oureverydaylife.com/ 0-how-to-use-calcium-alginate.html on 03/04/2019 at 5:00 PM reflected: Calcium alginate is a substance formed from seaweed and used in specialized wound dressings. The purpose of calcium alginate is to combine with wound drainage to form a gel in the moist wound bed. Trim the calcium alginate dressing to fit the wound. Make sure you do not apply the dressing to healthy skin surrounding the wound. Apply the calcium alginate dressing to the wound. If the wound is deep, pack rolled gauze on top of the calcium alginate. Secure the dressing with a thick, absorbent pad and medical tape. The facility did not provide a policy for ulcer care.

Based on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for two of two residents reviewed for pressure ulcer care (Resident #1 and Resident #4). [NAME] The facility failed to follow professional standards for pressure ulcer treatment when Resident #1's sacral ulcer was not cleansed or packed during treatment and Resident #1's pressure ulcer had progressed to Stage III with slough and odor. B. The facility failed to follow professional standards when Resident #4's [MEDICATION NAME] ointment and medicinal dressing were not placed directly and only in the ulcer bed when Resident #4 had a stage IV pressure ulcer on his lateral foot. Resident was not wearing a heel protector as ordered by physician. These failures to provide ulcer care using professional standards could lead to declines in ulcers, infection,[MEDICAL CONDITION], and death for residents who have or develop ulcers. Findings included: [NAME] Review of Resident #1's Face sheet reflected she was a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS dated [DATE] reflected she had a BIMS score of 12 which indicated she had moderate cognitive impairment, no behaviors, and needed extensive assistance of two people for bed mobility and transferring. She was frequently incontinent. She was coded to have one Stage III ulcer. Review of Resident #1's care plan reflected; Problem start date 04/22/2018 Pressure ulcer Stage III to coccyx. Goal: Pressure ulcer will show signs of healing and remain free of infection through next review. Interventions included; Administer treatments as ordered and monitor for effectiveness. Provide supplemental protein, amino acids, vitamins and minerals as ordered to promote wound healing. Provide with pressure relieving cushion while up in wheelchair. Pressure relieving mattress. An additional care plan reflected Resident #1 was at risk for pain in her lower back and lower extremities. Review of Resident #1's Skin Treatment flow sheet dated (MONTH) 2019 reflected an order dated 02/23/2019 for Sacrum - Cleanse with normal saline, pat dry, apply santyl, calcium alginate and foam or dry protective dressing daily and as needed. Review of Resident #1's Physician order [REDACTED]. 07/06/2018 for Multi-vitamin one daily for pressure ulcer of sacral region, stage II and vitamin C 500 mg one daily for pressure ulcer of sacral region, stage II. 08/10/2018 for supplemental nutrition; Medpass 60 ml (two ounces) three times a day for wound healing. 02/21/2019 reflected Santyl ointment, dime thick; topical. [DIAGNOSES REDACTED]. 2/23/2019 reflected; Sacrum - Cleanse with normal saline, pat dry, apply santyl, calcium alginate and foam or dry protective dressing daily and as needed. Additional orders included; heel protectors to off load pressure, float heels in bed, add fortified foods to all meals, house shake daily on dinner tray and gel cushion to wheelchair. Review of Resident #1's (MONTH) 2019 Medication Flowsheet reflected Resident #1 received [MEDICATION NAME] 300 mg one tablet three times a day for general pain routinely. Further review reflected Resident #1 did not receive any prn pain medication on (MONTH) 1st which indicates resident did not receive any additional pain medicine prior to wound treatment on 3/1/19. On (MONTH) 2nd Resident #1 received one Tylenol with [MEDICATION NAME] #3 for pain as needed one time and ADON D's initials were on the flowsheet. This medication was administered after wound care as noted in observation below. Review of Resident #1's Wound Evaluation and Management Summary reports by the wound physician that visited weekly reflected: sacral pressure ulcer stage III (three). 02/01/2019 Measurements: 1.2 x 0.3 x 1.4 cm with 2.0 cm of undermining (tunneling) at 12 o'clock (towards her head). Duration of treatment greater than 217 days. Exudate; moderate serous, slough (dead) - 30%, granulation - 70%, Deteriorated. Wound cleansed with normal saline, anesthetized, surgically excised .11 cm squared of devitalized tissue including slough, biofilm and non-viable subcutaneous fat .to a depth of 1.4 cm . Treatment; continue with collagen powder, calcium alginate and foam with boarder dressing. 02/07/2019 Measurements; 0.9 x 0.3 x 1.4 cm undermining 2.0 cm at 12 o'clock. Exudate; moderate serous, 100% granulation (healthy tissue). Improved. Treatment; collagen powder, calcium alginate and foam with boarder dressing once daily. 02/14/19 Measurements; 0.7 x 0.2 x 1.4 cm undermining 2.0 cm at 12 o'clock. Exudate; heavy serous, 100% granulation tissue. Improved. Treatment; collagen powder, calcium alginate and foam with boarder dressing once daily. 02/21/19 Measurements; 1.5 x 1.2 x 1.6 cm, undermining 2.0 cm at 12 o'clock. Exudate; moderate serous, 70% granulation tissue and 30% slough. Deteriorated. Excised (cut out) 0.54 cm of devitalized tissue. Bio film and non-viable subcutaneous fat at a depth of 1.8 cm. Debridement/removed thick, adherent eschar (dead), necrotic (dead) tissue and established margins of vital tissue (living). Treatment; (new) Santyl, calcium alginate and foam with boarder dressing once daily. 02/28/19 Measurements; 1.5 x 1.2 x 2.0 cm, undermining 2.0 cm at 12 o'clock. Exudate; moderate serous, 50% granulation and 50% slough. Deteriorated. Excised (cut out) 0.90 cm of devitalized tissue. Bio film and non-viable sub cutaneous fat at a depth of 2.0 cm. Debridement/removed thick, adherent eschar and devitalized tissue (dead) and necrotic tissue to re-establish the margins of vital tissue. In an observation/interview on 03/02/2019 at 12:35 LVN [NAME] brought supplies to provide ulcer care to the bed side and laid them on the bed directly beside Resident #1. While LVN [NAME] washed her hands, Resident #1 made sad sounds and stated she was in pain. LVN [NAME] came back to the room and told Resident #1 to roll over on her side. Resident made a sad sound saying, It hurts. LVN [NAME] stated she would be as gentle as she could be but did not offer any pain medication. LVN [NAME] rolled Resident #1 over on her right side and the daughter held her over. When LVN [NAME] lowered Resident #1's brief, surveyor observed tan/brown wound drainage on the brief the size of a half dollar and an approximately 3.0 cm dark hole in Resident #1's sacrum. There was an approximately 0.33 cm wide and 1.0 cm long flap of green dead tissue protruding from the edge of the ulcer on the right side. Immediately around the pressure ulcer opening, the epidermis (top layer of skin) was macerated (white with moisture) and was sloughing off in places revealing raw skin. There was no dressing in place. Resident #1's daughter stated, I see why she is complaining about pain now. Oh, the smell is putrid. LVN [NAME] donned gloves and took 4 x 4s off the bed and squirted normal saline on gauze and wiped the skin surrounding the opening three times with three different gauze 4 x 4s. Then with the same contaminated gloves on, she put her finger in the medicine cup of ointment and rubbed santyl only on the macerated and the healthy skin around the ulcer opening. LVN [NAME] did not cleanse or treat the pressure ulcer, only the surrounding skin. LVN [NAME] changed gloves, (did not sanitize or wash her hands) and opened calcium alginate and placed the rectangular square on the macerated and healthy skin surrounding the opening and not in the ulcer bed. After LVN [NAME] opened the foam dressing cover and was about to place it on the skin, surveyor stopped LVN [NAME] and had ADON D look at the manner of the application of the ointment and dressing. Surveyor told ADON D LVN [NAME] had washed the surrounding skin, put santyl ointment on the surrounding skin and placed the calcium alginate on the surrounding skin. ADON D looked at the santyl on the surrounding skin, the calcium alginate rectangle on the skin (covering over the open ulceration) and stated it was fine and asked to see the ulcer. LVN [NAME] raised her calcium alginate rectangle to reveal the open hole with no packing and the ADON D stated, Oh, ok. Go ahead. LVN [NAME] lowered the calcium alginate back on the surrounding skin and put the foam border dressing over the santyl and calcium alginate. The daughter stated, The smell will knock you out. Resident #1 moaned and ADON D stated, I will get her something for pain and left the room. LVN [NAME] wrote the date on the dressing. Took her gloves off, opened the door and got more gloves and said she would have the aide come change the brief (because it had wound drainage on it that was high odor). In an observation on 03/02/2019 at 12:49 PM ADON D brought Resident #1 a Tylenol #3 pain tablet and administered it (after LVN [NAME] performed ulcer care). In an interview on 03/02/2019 at 3:10 PM the ADON D stated Resident #1 had a significant ulceration. The DON stated, I have not seen Resident #1's ulceration yet but I heard it is getting better. B. Review of Resident #4's Face Sheet reflected he was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #4's Quarterly MDS dated [DATE] reflected a BIMS score of nine which indicated he had moderate cognitive impairment. He had no behaviors, and required extensive assistance of two people for transferring, and bed mobility. Section I, Active Diagnoses, did not reflect he had a pressure ulcer. Section M, Skin Conditions, reflected he had a stage four pressure ulcer. Review of Resident #4's Care plan dated 01/08/2019 reflected; Resident is at risk for pressure ulcer due to impaired mobility. Goal; Intact skin without evidence of redness, irritation, maceration, or open areas. Approach; skin assessment and inspections weekly and turn and reposition every two hours and as needed. The care plan did not reflect Resident #4 had any pressure ulcers. Review of Resident #4's Physician order [REDACTED]. 11/27/18; Med pass 60 ml (two ounces) twice a day [DIAGNOSES REDACTED]. 01/25/2019 Right plantar/lateral foot - cleanse with normal saline, pat dry, apply santyl, calcium alginate and cover with dry protective dressing daily. 02/19/19 Santyl ointment, dime thick topical, 1.7 x 1.5 [DIAGNOSES REDACTED]. Review of Resident #4's Treatment Administration record dated (MONTH) 2019 reflected an order for [REDACTED]. Review of Resident #4's Wound Evaluation and Management Summary reports by the wound physician that visited weekly reflected: 02/28/2019 - Stage IV (four) pressure wound of the right, distal, lateral foot. 1.7 x 1.5 x not measurable. Surface area 2.55 cm squared. Duration: greater than 105 days. Exudate: Moderate Serous, thick adherent devitalized necrotic tissue 5%, Granulation tissue 95%, Improved. After anesthetize, 0.13 cm squared of devitalized tissue and necrotic muscle . were removed at a depth of 0.6 cm and healthy bleeding tissue was observed. (On 02/28/19 after the wound doctor debrided the ulcer, it was 0.6 cm deep and red granulating tissue only). In an observation on 03/02/2019 at 3:47 PM Resident #4 was in a recliner in his room with no pressure relief devices on. His right heel was flat on the recliner foot rest. The DON cued LVN [NAME] to get a disposable pad to provide a clean field before she started wound care on the recliner foot rest. LVN [NAME] provided wound care and started by placing Resident #4's socked foot in the middle of the clean field. LVN [NAME] removed the sock and the dressing to reveal Resident #4's ulceration to his lateral right foot at the base of the fifth toe. After LVN [NAME] removed the square piece of calcium alginate dressing that was only partially in the wound bed, the ulcer was observed to be approximately 5 mm deep. The bed of the ulcer was approximately 80% covered with green slough and therefore it was not stageable. (All slough had previously been removed on 02/28/2019 therefore the ulcer bed had significantly declined.) The ulcer was surrounded almost entirely by white, wet, macerated skin due to the calcium alginate treatment (which gathers moisture) was cut in a square and was not just in the wound bed but also on most of the surrounding skin. The DON told LVN [NAME] to get out some sanitizer for her hands and also to sanitize the scissors she had removed from her fanny pack during wound care. LVN [NAME] used her gloved finger to apply santyl ointment in and all around the ulcer on the surrounding skin. She placed a rectangular calcium alginate across the entire opening and on the surrounding skin all around the ulcer. The calcium alginate was across the wound bed, (like a roof) and not touching the wound bed. The DON did not redirect LVN [NAME] to cut the calcium alginate to fit in the wound bed. LVN [NAME] wrapped Resident #4's foot with gauze and taped it. In an interview on 03/02/2019 at 3:47 PM the DON stated, For pressure relief, he has something propping his feet off his bed. This is the first time I have seen him in that chair. It looks like we will need to get something for him for this chair for pressure relief. In an interview on 03/02/2019 at 4:15 PM LVN [NAME] stated she did not know what action santyl had on an ulcer, she stated she did not know what calcium alginate was for or that it was supposed to be directly touching the ulcer bed only. LVN [NAME] stated she saw that Resident #4's skin surrounding the ulcer was white with moisture damage, but she did not realize the ointment and calcium alginate would cause the moisture damage. LVN [NAME] stated the order said to put the santyl on topically. She stated she did not pack the ulcer for Resident #1 because she did not have an order to pack the ulcer. LVN [NAME] stated she didn't know the santyl and calcium alginate cannot heal the ulcer if applied on the surrounding skin only (Resident #1). In an interview on 03/02/2019 at 4:25 PM the DON stated the santyl is supposed to only be put in the ulcer and the calcium alginate is only supposed to be put in the ulcer. She stated Resident #4's ulcer was macerated with moisture and should not be. She stated Resident #1's ulcer should have been packed and the orders for both resident's ulcer treatments should have been worded plainly that the santyl and calcium alginate were to be placed in the ulcer bed. The DON stated she had to cue LVN [NAME] during ulcer care for infection control, but the wound care products representative had told the nursing staff they could use a gloved finger to apply ointments to wounds and it wouldn't hurt to put the ointment on the healthy surrounding skin also. In an interview on 03/02/2019 at 5:20 PM the Medical Director he expected the nurses to follow the MD orders, but they may be following them in a simplistic manner at times. The Medical Director stated; Wound care is a multi-focal process (clear physician's orders [REDACTED]. When we do wound care for a wound that is of depth (at the clinic), we irrigate the wounds inner areas to cleanse them. We pack the inner wound for a while at least (place the prescribed healing agent in the wound bed). We use less and less of packing as it heals; three inches (of packing materials) then two inches and so on, so as not to cause pressure but to cleanse the inner wound. In an interview on 03/06/2019 at 1:22 PM the Wound Care MD stated he evaluated, measured and performed the treatment on the ulcers for Residents #1 and #4 every week. The Wound Care MD stated when he administered medications to wound/ulcer beds he usually used a cotton swab to apply the ointment and the calcium alginate was cut to fit on the ulcer bed or it was tucked inside of an ulceration. He stated it was possible that ulcer treatment being delivered in the manner the surveyor observed could play a role in the deterioration of the wounds but that both residents had multiple [DIAGNOSES REDACTED]. He further stated he usually had his patients receive pain medicine before he delivered care. He stated putting the supplies on the bed could lead to cross contamination and putting a sock in the middle of the clean field voided the clean field. He further stated he thought that the nurses at the facility were aware of the basic principles of wound care. Review of the website: https://www.santyl.com/hcp/dosing on 03/04/2019 at 4:41 PM reflected; Indication - Santyl Ointment is indicated for [MEDICATION NAME] chronic dermal ulcers and severely burned areas. Important Safety Information: Use of Santyl ointment should be terminated when debridement is complete and granulation tissue is well established. How to apply: Apply SANTYL Ointment out to the edges of the wound. Take care not to extend beyond the wound surface although it does not harm healthy tissue. A video on the website reflected the ointment was to be applied with a wooden applicator within the wound bed only. Occasional slight transient [DIAGNOSES REDACTED] has been noted in surrounding tissue when applied outside the wound. Review of the website; https://oureverydaylife.com/ 0-how-to-use-calcium-alginate.html on 03/04/2019 at 5:00 PM reflected: Calcium alginate is a substance formed from seaweed and used in specialized wound dressings. The purpose of calcium alginate is to combine with wound drainage to form a gel in the moist wound bed. Trim the calcium alginate dressing to fit the wound. Make sure you do not apply the dressing to healthy skin surrounding the wound. Apply the calcium alginate dressing to the wound. If the wound is deep, pack rolled gauze on top of the calcium alginate. Secure the dressing with a thick, absorbent pad and medical tape. The facility did not provide a policy for ulcer care.

Based on observation, interview and record review the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for two of two residents reviewed for catheters (Resident #2 and #3). [NAME] The facility failed to routinely assess Resident #2's fluid intake and output, and urinary functions while he was on skilled nursing care for a Urinary Tract Infection after having a UTI on 1/21/19, [MEDICAL CONDITION] stent replacement on 2/07/19, and a chronic indwelling urinary catheter. Resident #2 subsequently suffered septic shock/urinary source and was hospitalized in ICU on 2/24/2019. B. The facility failed to ensure Resident #3 received care to prevent Urinary Tract Infections when they stored her catheter bag on the floor and did not empty it at the customary time - the end of the shift. These failures to provide routine catheter care could have increased the risk of infections and septic shock leading to death. Findings Included: [NAME] Review of Resident #2's Face Sheet reflected he was an [AGE] year old male admitted on [DATE] and readmitted on [DATE] with Medicare part A benefits pay source for skilled nursing services, with [DIAGNOSES REDACTED]. Review of Resident #2's most recent MDS which was a 30 day Medicare billing MDS dated [DATE] reflected his most recent admission to the facility was on 01/25/2019 when he started his most recent Medicare billing stay. Resident #2's BIMS was eight which indicated moderate cognitive impairment. He required extensive assistance of one person for bed mobility, transferring, locomotion on and off the unit and personal hygiene, he was supervision/oversight, encouragement for eating. Review of Resident #2's care plan dated 06/14/2018 and updated on 12/20/2018 reflected; Potential for complications related to [DIAGNOSES REDACTED]. Goal; free of urinary tract symptoms through review. Administer meds as ordered and monitor for side effects, effectiveness. Assess/record/report to MD as needed for bladder distention, bladder spasms, flank or back pain, increased urinary residual, UTI. Encourage adequate fluid intake to reduce risk of UTI. Obtain lab work as ordered. Report results to MD and follow up as indicated. Provide cranberry juice. Further review of the care plan reflected; Resident at risk for nutritional impairment and interventions were red plate with meals, maintain accurate meal intake record, praise for good dietary compliance, supplements and snacks as ordered/desired within restrictions. An additional care plan for Resident #2 reflected; Indwelling Catheter. Resident will have catheter care managed appropriately as evidence by not exhibiting signs of infection or urethral trauma. Assess drainage. Record the amount, type, color, odor. Observe for leakage. Change catheter per MD order. Review of Resident #2's hospital records reflected; Registration date and time; 01/21/2019 10:02 AM [DIAGNOSES REDACTED]. Normal 4.5 to 13. Impression: Dehydration and Acute [MEDICATION NAME] (urinary tract infection). On evaluation in the ER, he was found to have evidence of UTI and was also found to have debris blocking foley catheter on bladder scan. The foley catheter was subsequently replaced in the ER. He has leukocytosis (high white blood cell count) with a baseline WBC count of 27,000. (Resident #2's WBC baseline/average count was about 27,000 instead of 4.5 to 13 x 10'3 because of his [MEDICAL CONDITION].) Discharge Instructions print out: Drink at least 12 eight ounce glasses of water a day to resolve dehydration. Registration date and time 02/07/19 at 7:57 AM Diagnosis; Breakdown of indwelling urinary stent. A 26 cm [MEDICAL CONDITION] stent was placed in the left and right ureters. (The record reflected Resident #2 had bilateral urinary stents to ensure his body was able to deliver the urine from the kidney to the bladder. He had the stents so long they had broken down and had to be replaced. This situation was found during the hospitalization of 01/21/2019). Registration date and time; 02/24/2019 at 5:48 AM. Diagnosis;[MEDICAL CONDITION]. emergency room record; Nursing home staff found him not as responsive as usual this morning, nonverbal, not moving. EMS found the patient febrile at 101 degrees Fahrenheit, totally altered, not maintaining his airway and with [MEDICAL CONDITION] to 50 systolic. Apparently nursing home staff state he was in normal state health last night prior to bed. Physical exam: obtunded, acutely ill. Very dry oral mucosa. White blood cells 90.8 x 10'3. Critically high. Urine: turbid (cloudy), large blood, white blood cells too numerous to count, red blood cells too numerous to count, bacteria - many. Patients baseline white blood cell count appears to be between 20 and 30 (x 10'3) secondary to his chronic lymphocytic [MEDICAL CONDITION]. He is admitted to the ICU with septic shock secondary to urinary source. Review of Resident #2's Consolidated Physician order [REDACTED].#2's readmission from the hospital; [MEDICATION NAME] 0.4 mg at bedtime [DIAGNOSES REDACTED]. [MEDICATION NAME] V potassium 5000 mg tablet four times a day [DIAGNOSES REDACTED]. [MEDICATION NAME]-[MEDICATION NAME] 400-80mg tablet one twice a day [DIAGNOSES REDACTED]. Review of Resident #2's Progress Notes reflected 02/19/2019 was the last entry regarding Resident #2's urine description prior to him having to leave the facility in an ambulance on 02/24/2019. Below are the nurse notes regarding resident #2 in their entirety; 02/17/2019 5:14 PM Staff continues to encourage fluids throughout shift, taken fair. Resident able to drink two 5 ounce glasses of water prior to laying down after meals. 02/19/2019 5:49 PM Resident up in his wheelchair, continue to yell out for help while propelling self to the dining area, resident re-directed to behaviors but continues to yell and get verbally abusive while addressed to not yell out, fluids encouraged and consumed, Resident on Medicare for urinary tract infection/altered mental status, indwelling Foley intact with clear yellow urine noted to urinal tubing, no sediments noted. 02/20/2019 6:40 PM Resident continues to be on Medicare with therapy as scheduled, no noted distress. 02/24/2019 6:14 AM This nurse advised of change of condition. Vitals 68/40 (manual), (respirations) 20, (heart rate)91, 98.6 and (oxygen saturation) 66%. order for ER .5:30 AM EMT (paramedics) arrived and .transported to hospital. 03/01/2019 5:31 PM Resident arrived to facility from hospital via ambulance stretcher, assisted to bed, .Foley intact with clear yellow urine noted to urinal tubing, .redness to his bottom, cleanse area and applied ointment to area, resident on antibiotic therapy [MEDICAL CONDITION] . Review of Resident #2's Treatment flow sheet dated (MONTH) 20/2019 reflected; 02/20/19 Intake; 720 cc (three cups). Output; 920 cc with three nurses initialing. 02/21/19 Intake; 720 cc (three cups). Output; 1100 cc with three nurses initialing. 02/22/19 Intake; 1060 cc (4.5 cups). Output; 1200 cc with three nurses initialing the document. 02/23/19 Intake; 240 cc (one cup). Output; blank with three nurses initialing the document. Review of Resident #2's Skilled Notes- Infection reflected; 02/22/2019 9:56 AM Medicare - Urinary Tract Infection/Altered Mental Status Has the infection caused weakness? Decrease in functional abilities? Describe the effect on the resident: No recent effects from UTI. What interventions are in place to improve function? Fluids encouraged. Therapy? PT/OT/ST Resident is participating. Outcome? Improvement. Vital signs: 119/76, 65, 18, 97.8. oxygen saturation? 95%. The document did not cue the nurse to assess the urinary system, the description or amount of the urinary catheter contents, or resident intake and output and there was no assessment documented. The ADLs were scored by the nurse and eating was supervision, encouragement and set up help only, bed mobility was extensive assistance and toileting was total dependence. 02/23/09 11:33 PM (six hours before he was found unresponsive, hypoxic, hypotensive and febrile) Medicare - Urinary Tract Infection/Altered Mental Status Has the infection caused weakness? Decrease in functional abilities? Describe the effect on the resident: WEAKNESS. What interventions are in place to improve function? Antibiotic and fluids encouraged. Therapy? PT/OT/ST Resident is participating. Outcome? Improvement. Vital signs: 128/67, 75, 18, 97.8. oxygen saturation? 97%. The document did not cue the nurse to assess the urinary system, the description or amount of the urinary catheter contents, or resident intake and output and there was no assessment documented. The ADLs were scored by the nurse and eating was supervision, encouragement and set up help only, bed mobility was limited assistance and toileting was limited assistance. In an interview on 03/02/2019 at 6:20 PM the DON stated there was no documentation of whether Resident #2 was eating and drinking on 02/23/2019, the day before he had altered mental status and was sent to the hospital (2/24/19). She stated there was no documentation that reflected he had consumed his meals for any days before he went to the hospital on [DATE] in the computer due to no one had cued the computer to save the ADL data being entered. She stated there was no documentation of his urine color, amount or quality (after the nurse note of 2/19/19) except the intake and output document. She stated the facility wasn't required to document a full assessment (of the body system that had the infection that led to the resident's decline and need for skilled services). The DON stated she could not provide any more information regarding Resident #2's abilities or decline in the last few days before he went to the hospital on [DATE] except that he had therapy billing for minutes of therapy. In an interview on 03/02/2019 at 8:21 PM the therapist stated; There was one day he was in therapy with the speech therapist and occupational therapist, but I don't remember if it was Wednesday or Thursday (2/20 or 2/21/19). I remember Resident #2 shook my hand. On the day I am recalling, everyone said he was having a really good day. Usually if my staff notices a change they notify he nurses. It was a surprise he went to the hospital. I am not sure why he went to the hospital. In an interview on 03/02/2019 at 8:11 PM CNA G stated, When I got to work on the 24th I heard that Res. #2 was not doing good and all the nurses were working on him and 911 had been called. I worked the day before, but I don't know if I worked that hall or not. He usually called my name. We would send him out to the cafeteria. He is picky he wanted apple juice and coffee and he was set on getting up for all meals. The day before he went out, I don't know if I worked with him or not. I can't recall anything those days, my assignment changes. Every time he saw me he called my name out multiple times. In an interview on 03/02/2019 at 8:14 PM the Medication Aide H stated, I gave him his pills the day before he discharged . He was up and going to the dining room. I couldn't really tell you if he was eating or not. Whoever has the hall documents. He didn't have any problem talking his pills. He was his normal self. The night before I got off at 2:00 PM and he was fine. In an interview on 03/06/2019 at 4:30 PM Resident #2's Primary MD stated Resident #2's urinary system should have been monitored and documented due the resident having urinary tract infection that led to him being on skilled nursing, he had a catheter and he had [MEDICAL CONDITION] stents replaced. He stated it takes more than one symptom to determine there is a urinary problem and you cannot say there is something wrong because the urine has a foul odor or is cloudy, but you look at the whole assessment. He stated Resident #2's Chronic Lymphocytic [MEDICAL CONDITION] negated being able to quantify his illness based on the white blood cell count. Resident #2's Primary MD stated he could not say whether the facility was monitoring the resident or not but if they didn't document the assessments, we all know if you don't document what you were doing, it wasn't done. B. Review of Resident #3's Face sheet reflected she was a [AGE] year old female admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's Significant Change in status MDS dated [DATE] reflected she had a BIMS score of 15 which indicated no cognitive impairment, she was totally dependent on staff for transfers and required extensive assistance of two people for toilet use. Review of Resident #3's Care plan dated 12/21/2018 reflected she was incontinent of bladder. It did not reflect she had a urinary catheter. The MDS reflected she had returned the facility from the hospital on [DATE]. Review of Resident #3's Physician order [REDACTED]. 12/20/2018 Catheter care every shift ([DIAGNOSES REDACTED]. 12/12/2018 [MEDICATION NAME] 20 mg one tablet daily diagnosis; [DIAGNOSES REDACTED] (diuretic). 02/20/2019 record intake and output each shift daily. In an observation on 03/02/2019 at 1:04 PM Resident #3 was sitting in her bed and her urinary drainage catheter was lying directly on the floor under the bed. In an interview on 03/02/2019 at 1:04 PM Resident #3 surveyor asked Resident #3 if she had a urinary catheter. She stated, I have a bag around here somewhere, but I don't know where it is. The staff has to move the bag every time they move me, but I don't touch the bag. In an interview/observation on 03/02/2019 at 2:38 PM the Administrator called staff to get Resident #3's catheter bag off the floor and as staff raised it up it was observed the bag had 600 to 700 cc of urine in the bag. The Administrator stated Resident #3's catheter should not have been on the floor under Resident #3's bed and she stated the catheter bag should have been empty at that point in the day because shift change was half an hour earlier. The Administrator stated she expected the catheters to be off the floor and emptied at the end of each shift. In an interview on 03/06/2019 at 4:30 PM Resident #3's Primary MD stated catheters should not be on the floor because it leads to cross contamination (infection introduced into the urinary system through the catheter portal from the floor).