Every finding on record at Avir at Winnsboro

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 3 of 8 residents (Resident #37, Resident #53 and Resident #71) reviewed for pharmacy services.The facility failed to ensure LVN C did not leave Resident #37's medication on her bedside table on 8/10/2026.The facility failed to ensure Resident #53's medications were not left in Resident #37's room and on the bedside table on 8/10/2026.The facility failed to ensure Resident #71's over the counter eye drops were securely stored on the medication cart on 8/10/2026.These failures could place residents at risk for misuse of medication and overdose, adverse reactions of medications, and not receiving the therapeutic benefit of medications. 1. Record review of Resident #37's face sheet, dated 08/11/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #37 had diagnoses which included dementia (a syndrome characterized by a decline in cognitive function, affecting memory, thinking, behavior, and the ability to perform everyday activities), pulmonary hypertension (a type of blood pressure that affects the arteries in the lungs and the right side of the heart), cellulitis of right lower leg (a common bacterial skin infection that occurs when bacteria enters in through the cracks of the skin), and arthritis (a group of conditions that cause joint pain, stiffness, and inflammation, affecting mobility and quality of care). Record review of Resident #37's quarterly MDS assessment, dated 7/9/2026, indicated Resident #37 was understood and understood others. Resident # 37 had minimal difficulty hearing, clear speech, and adequate vision with corrective lenses. Resident #37's BIMS was 11, which indicated moderately impaired cognition. Resident #37 required set-up assistance with eating, toileting, dressing upper and lower body. Resident #37 required supervision with bathing and personal hygiene.Record review of Resident #37's care plan, revised on 5/7/2026, indicated Resident #37 had potential for injury related to medication allergies. Interventions included allergies to be assessed prior to administration of medications, allergies to be listed on MAR and on the chart and hold medication and notify MD of any reaction. The care plan also indicated Resident #37 had risk for adverse reaction related to polypharmacy (taking five or more medicines at the same time). Interventions included monitor for signs and symptoms of adverse drug reaction, request physician to review and evaluate medications and review resident's medication with MD/consulting pharmacist for duplicate medications or prescriptions, proper dosing, timing, and frequency of administration, adverse reactions, supporting diagnosis. Record review of Resident #37's MAR, dated 8/1/2026-8/31/2026, indicated Resident #37 was administered the following morning medications:Ferrous Sulfate 325 mg tablet 1 tablet every other day for iron deficiency anemia (a condition characterized by deficiency of healthy red blood cells or hemoglobin, leading to insufficient oxygen delivery to the body's tissues).Losartan Potassium 50 mg 1 tablet by mouth for hypertension (a common condition where the blood force against the artery walls is consistently too high).Metoprolol Succinate ER 25 mg 1 tablet every day for hypertension.Spironolactone 25 mg 1 tablet daily for diuretic (medications that increase urine production by helping the kidneys remove extra salt [sodium] and water from the body).Vitamin D 3 25 mcg 1 tablet daily for vitamin D deficiency (a deficiency of Vitamin D in body).Warfarin 5 mg 1 tablet on Monday, Tuesday, Wednesday, Thursday for mitral valve regurgitation (a common type of heart valve disease).Citracal + Vitamin D3 with vitamins with minerals 2 tablets twice daily for vitamin deficiencyGabapentin 100 mg 2 capsules twice daily for arthritis (a group of conditions that cause joint pain, stiffness, and inflammation, affecting mobility and quality of care).Neurontin 300 mg 2 capsules three times daily for arthritis During an observation and interview on 8/10/2026 at 9:40 AM, Resident #37 said the nurse left her medication on her bedside table if she was busy. Resident #37 said she received her medications timely. Observed a medication cup on Resident #37 bedside table, labeled as Resident #53's medication cup with 8 different medications 2 white round pills, 2 white oval tablets, 1 yellow capsule, 1 square beige tablet and 1 round blue tablet and 1 beige colored capsule. Resident #53 was not Resident #37's roommate. Resident #71 was Resident #37's roommate and was returning to her room from therapy. During an interview on 8/10/2026 at 9:55 AM, LVN C said she left Resident #37's medication on the bedside table this morning because Resident #37 was on her phone. During an interview on 8/10/2026 at 10:18 AM, LVN C said she was supposed to watch Resident #37 take her medications. LVN C said she was not aware of any other resident's medication being in the room with Resident #37. LVN C said another resident's medication should not be in Resident #37 and Resident #71's room. LVN C said the residents could have a negative effect if they took the wrong medications. LVN C said she did not know how Resident #53's medication got in Resident #37's room. LVN C said she was responsible for ensuring the residents take their medications prior to leaving the room. During an interview on 8/12/2026 at 10:26 AM, CNA G said residents should be administered their medication while in their room. CNA G said medication cups should not be left in the residents' rooms. CNA G said she would report to the nurse if medication was identified in a resident's room. CNA G said the nurse or MA who was administering the medication was responsible for ensuring the medication was taken. CNA G said residents should have an order for eye drops and if a resident used eye drops that were not prescribed, it could be dangerous. During an interview on 8/12/2026 at 10:43 AM, LVN D said residents should not have medications in their room. LVN D said no one her hall was able to self-administer medications. LVN D said the medication cups with the resident medication should not be left with the residents. LVN D said the nurse should make sure the resident took their medication while the nurse was in the room. LVN D said the nurse was responsible for ensuring the medication was taken while in the room. LVN D said a resident could store the medication and take it later, choke, or another resident could take the medication. During an interview on 8/12/2026 at 11:06 AM, the MDS nurse said she worked the floor as needed. The MDS nurse said medications should not be left in a resident room and the nurse should ensure the medication was swallowed. The MDS nurse said another resident could get the medications and take them or the medications could spill. The MDS nurse said leaving the medications in the resident's room could be detrimental to the health of the resident if the medication was not taken because it was medication the resident needed. The MDS nurse said the nurse or MA who administered the medication was responsible for ensuring the medication was taken. The MDS nurse said a resident could have an adverse reaction if the medication was taken at the wrong time. During an interview on 8/12/2026 at 11:15 AM, ADON A said medication should not be in the resident room. ADON A said the MA or nurse should watch the residents take the medications prior to leaving the room. The resident may not take them; someone could get ahold of them. ADON A said the resident could have an adverse reaction with whatever medication such as blood thinners or blood pressure medications. ADON A said whoever administered the medication was responsible. During an interview on 8/12/2026 at 11:52 AM, the DON said the nurse should watch the residents take their medications. The DON said the nurse who administered the medications were responsible for ensuring the medications were taken. The DON said someone could have gotten ahold of the medications and had an adverse reaction such as allergic reaction or death. During an interview on 8/12/2026 at 12:09 PM, the ADM said he did not know the medication policy. The ADM said in most facilities you would not leave medication in a resident room. The ADM said leaving medications in a resident room could affect the residents' health if they did not take them as scheduled. The ADM said another resident could take the medications. The ADM said a resident could take the wrong medication which could impact the resident's health causing a decline, allergic reaction, and depending on the medication such as a non-diabetic taking a diabetic medication could cause a blood sugar drop. The ADM said the MA or nurse was responsible for ensuring the medications were taken. 2. Record review of Resident #53's face sheet, dated 08/11/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included Type II Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication), Pneumonia (an infection that inflames the air sacs in one or both lungs, which may fill with flid or pus, leading to symptoms), Chronic obstruction pulmonary disease (a progressive lung disease that makes it difficult to breathe, primarily caused by long-term exposure to irritants like cigarette smoke and air pollution), and chronic pain syndrome (a condition that lasts for over three months and affects any part of the body). Record review of Resident #53's quarterly MDS assessment, dated 6/1/2026, indicated Resident #53 was understood and understood by others. Resident # 53 had adequate hearing, clear speech, and impaired vision. Resident #53's BIMS was 12, which indicated moderately impaired cognition. Resident #53 required set-up assistance with eating, toileting, dressing upper and lower body. Resident #53 required supervision with bathing. Record review of Resident #53's care plan, initiated on 3/15/2026, indicated Resident #53 had pain related to idiopathy neuropathy ( type of nerve damage where the cause is unknown, leading to symptoms like numbness, pain, and balance issues), gout (a condition that can cause attacks of a type of arthritis (joint inflammation), and low back pain. Interventions included administer analgesic as ordered, anticipate the resident's need for pain relief and respond immediately to any complaint of pain, and monitor/record/report to nurse any signs or symptoms of non-verbal pain and observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease range of motion, withdrawal or resistance to care. Record review of Resident #53's MAR, dated 8/1/2026-8/31/2026, indicated Resident #53 was administered the following medications every morning:Fish Oil 1000 mg 1 capsule by mouth daily for mixed hyperlipidemia (a condition characterized by elevated levels of cholesterol in the blood)Jardiance 10 mg 1 tablet by mouth daily for diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels)Pantoprazole Sodium 40 mg 1 tablet by mouth for GERD (a chronic condition where stomach acid flows back into the esophagus, leading to symptoms of heartburn, regurgitation, and irritation of the esophageal lining).Toprol XL 25 mg 1 tablet by mouth daily for Hypertension (a common condition where the blood force against the artery walls is consistently too high)Vitamin B 12 1000 mg 1 tablet daily for vitamin deficiency.Neurontin 300 mg 1 capsule by mouth twice daily for neuropathy (nerve damage or dysfunction)Hydrocodone-Acetaminophen 5-325 mg three times daily for pain.Sucralfate 1 gm 1 tablet before meals and at bedtime for esophageal reflux (a chronic condition where stomach acid flows back into the esophagus, leading to symptoms of heartburn, regurgitation, and irritation of the esophageal lining).During an interview on 8/10/2026 at 10:03 AM, Resident # 53 said she took her medication to Resident #37's room. She said she left the medication in Resident #37's room and left the room to get coffee. Resident #53 said she took the medications when she returned. During an interview on 8/10/2026 at 10:18 AM, LVN C said she was not aware of any other resident's medication being in the room with Resident #37. LVN C said another resident's medication should not be in Resident #37 and Resident #71's room. LVN C said the residents could have a negative effect if they took the wrong medications. LVN C said she did not know how Resident #53's medication got in Resident #37's room. LVN C said she was responsible for ensuring the residents took their medications prior to leaving the room. During an interview on 8/12/2026 at 10:26 AM, CNA G said residents should not leave their medications in another resident's room. CNA G said another resident could take the medication and cause death if taken. CNA G said the nurse was responsible for administering the medication and should not leave medications in rooms. During an interview on 8/12/2026 at 10:43 AM, LVN D said other resident should not have their medications in another resident's room. LVN D said the medication could get mixed up and an adverse reaction could occur if a resident got confused about which medication was theirs. LVN D said a resident could have an allergic reaction, get sick and there was a potential for death. LVN D said the nurses and MAs were responsible for ensuring medications were taken prior to leaving the room. During an interview on 8/12/2026 at 11:06 AM, the MDS nurse said the residents should not take their medications in another resident room. The nurse should make sure the resident took the medication prior to leaving. Another resident could take the wrong medications. They could have an adverse effect if the medication was prescribed for diabetes and the resident who took them was not a diabetic. The nurse or MA were responsible for ensuring the medications were taken. During an interview on 8/12/2026 at 11:15 AM, ADON A said Resident #53's medications should not have been left in Resident #37's room. ADON A said the nurse should have made sure the medications were taken when they were given to the resident. Adverse reaction, taking the wrong medication, blood thinner, blood pressure issues could occur. During an interview on 8/12/2026 at 11:52 AM, the DON said the nurse should watch the residents take their medications. The nurse who administered the medications was responsible for ensuring the medications were taken. The DON said someone could have gotten ahold of the medications and had an adverse reaction such as an allergic reaction or death. During an interview on 8/12/2026 at 12:09 PM, the ADM said the resident should not take medications in another resident room. The nurse should ensure the medications were taken before leaving the room. The ADM said another resident could take the medications. Taking the wrong medication could impact the resident health cause a decline, allergic reaction, depending on the medication non-diabetic taking a diabetic medication could cause blood sugar drop. The ADM said the MA or the nurse charge was responsible for ensuring the medications were taken. 3. Record review of Resident #71's face sheet, dated 08/11/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #71 had diagnoses which included metabolic encephalopathy (a reversible or sometimes permanent brain dysfunction caused by metabolic disturbances such as liver failure, kidney failure, diabetes-related glucose abnormalities, electrolyte imbalance, or toxins), acute on chronic combined systolic and diastolic heart failure (a combined form of heart failure in which both pumping [systolic] and filling [diastolic] functions worsen suddenly), Type II Diabetes (a chronic condition characterized by insulin resistance and high blood sugar levels, often manageable through lifestyle changes and medication), and macular degeneration (an irreversible vision loss in adults). Record review of Resident #71's quarterly MDS assessment, dated 6/25/2026, indicated Resident #71 was understood and understood by others. Resident #71 had minimal difficulty hearing, clear speech, and highly impaired vision. Resident #71's BIMS was 9, which indicated moderately impaired cognition. Resident #71 required set-up assistance with eating and required supervision with toileting and dressing upper and lower body. Resident #71 required moderate assistance with bathing and personal hygiene. Record review of Resident #71's care plan, revised on 5/7/2026, indicated Resident #71 had impaired cognitive function or impaired thought processes related to metabolic encephalopathy. Interventions included administering medication as ordered, ask yes/no questions in order to determine the resident's needs. Resident #71's care plan also indicated she had impaired visual function related to macular degeneration. Interventions included identify/record factors affecting visual function including physiological, environmental, choices, monitor/document/report any signs or symptoms of acute eye problems, review medications for side effects which affect vision, and resident prefers to have their room and things arranged to promote independence. Record review of MAR dated 8/1/2026-8/31/2026 indicated Resident #71 did not have an order for Systane eye drops. During an observation and interview on 8/10/2026 at 10:21 AM, Resident #71 was observed sitting up in her wheelchair with her oxygen on. Resident #71 said the over-the-counter eye drops were hers and said she put the drops in her eyes by herself. Two bottles of Systane eye drops located on Resident #71's bedside table was observed. Resident #71 did not say how she obtained the eye drops. Resident #71 did not have orders for Systane eye drops on her MAR. During an interview on 8/12/2026 at 11:15 AM, ADON A said Resident #71 should have an order for eye drops and they should not be stored on the bedside table. The eye drops should be stored on the medication cart. Cross contamination, eye irritation, and allergic reactions could occur. The ADON did not indicate why resident had eye drops on her beside table. During an interview on 8/12/2026 at 11:15 AM, the DON said there was no one at the facility who could self-administer medications or eye drops. The DON said there should be an order for Resident #71's eye drops and the eye drops should not be on the resident bedside table. The eye drops should be stored in the medication room or the medication cart. The DON stated she expected the medications to be observed taken and no medications left at the resident's bedside. During an interview on 8/12/2026 at 12:09 PM, the ADM said he would expect an order for the eye drops, care planned and assessed for self-administration for medication. The charge nurse was responsible for ensuring orders and care plans. During an interview on 8/12/2026 at 12:09 PM, the ADM said he did not know the medication policy. Most facilities would not leave medication in a resident room. It could affect the residents' health if they did not take them as scheduled. The ADM said another resident could take the medications. Taking the wrong medication could impact the resident health, cause a decline, allergic reaction, depending on the medication, non-diabetic taking a diabetic medication could cause blood sugar drop. The MA or the charge nurse were responsible for ensuring the medications were taken. During record review of the facility's policy, revised February 2023, titled Medication Labeling and Storage indicated .The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls.Policy Interpretation and Implementation.1. Medication and biological are stored in the packaging, containers, or other dispensing systems in which they are received.2. The nursing staff are responsible for maintaining medication storage and preparation areas .4.compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications or 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 observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure chicken and sausage were properly thawed. 2. The facility failed to ensure hard boiled eggs, cookies, and pimento sandwiches were labeled and dated. These deficient practices could place residents at risk for food borne illness.The findings were: During an observation on 8/10/2026 at 9:02 a.m. it was observed that raw chicken was being thawed in a strainer in the kitchen sink with water flowing onto some of the chicken. The water was draining and not filling up the sink. There was a container labeled smoke sausage sitting on a preparation table that was frozen and thawing out. There was a plastic bag with chocolate chip cookies on a preparation table, hard boiled eggs, Pimento sandwiches in the refrigerator were not labeled and dated. During an interview on 8/12/2026 at 10:40 a.m., the Dietary Manager said meat should be thawed by leaving it in the refrigerator to slowly thaw out or by submerging it under water with a stream of cool water continuously running. She said meat should not be thawed by leaving it in the sink with only some of the meat coming into contact with water. She said meat should also not be left frozen solid and thawing on a preperation table. She said food should be labeled and dated when stored. She said residents could be placed at risk of foodborne illness if they ate food that was spoiled or thawed improperly. During an interview on 8/12/2026 at 11:18 a.m., the Director of Nurses said all kitchen staff were responsible to ensure foods were being thawed properly and foods were labeled and dated. She said meat thawed in the sink should be fully submerged with water continuously running agitating the surface of the water per regulations. She said residents could be placed at risk of foodborne illness if food was not thawed or stored properly. During an interview on 8/12/2026 at 12:05 p.m., the Administrator said he expected all food served from the kitchen was stored, thawed and prepared according to regulations. He said residents could be placed at risk of foodborne illness if food was not stored or prepared properly. He said all kitchen staff were responsible to ensure food was stored and prepared properly. Record review of the facility's policy titled, Food Preparation and Service, dated November 2022 revealed, Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Danger Zone means temperatures above 41 degrees Fahrenheit and below 135 degrees Fahrenheit that allow the rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially Hazardous Foods or Time/Temperature Control for Safety Foods held in the danger zone for more than 4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) may cause a foodborne illness outbreak if consumed.Completely submerging the item in cold running water that is running fast enough to agitate and remove loose ice particles. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread off foodborne illness.

Based on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care for 1 of 5 residents reviewed for baseline care plans. (Resident #68) The facility failed to develop and implement a baseline care plan within 48 hours of admission on [DATE] for Resident #68. This failure could place newly admitted residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 08/11/2026 indicated Resident #68 was an [AGE] year old male who was admitted on [DATE] with diagnosis including senile degeneration of brain (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), anxiety (an emotion characterized by an unpleasant state of inner turmoil and feelings of dread), hypertension (a common condition where the force of blood against the artery walls is consistently too high), and benign prostatic hyperplasia (an enlarged prostate). Record review of Resident #68's admission MDS indicated it had not been completed at the time of inspection completion on 8/12/2026. Record review of the progress note dated 8/11/2026 indicated Resident #68 was admitted to the facility for respite care on 7/31/2026 through hospice care and then discharged on 8/5/2026 home. Resident #68 readmitted on [DATE] for long-term care with hospice care. During an interview on 8/12/2026 at 10:17 AM, CNA G said the baseline care plans were located on the electronic medical record. CNA G said the baseline care plan was a guide on how they are supposed to care for the residents. CNA G said the baseline care plan indicated what the resident needs and preferences. CNA G said she could not recall Resident #68 having a baseline care plan. CNA G said the administration was responsible for putting in the baseline care plan. CNA G said the residents may not get the care they need. During an interview on 8/12/2026 at 10:39 AM, LVN D said she had not looked at Resident #68's care plan. LVN D said the MDS nurse coordinator, ADON, and DON were responsible for the baseline care plan. LVN D said the baseline care plan should be initiated upon entrance. LVN D said it was a guide on how to care for the residents. LVN D said the staff would not know how to care for the residents. LVN D said if the baseline care plan were not initiated, it could delay care for the residents. During an interview on 8/12/2026 at 10:59 AM, the MDS nurse said she does not complete the baseline care plan. The MDS nurse said Resident #68 did not have a baseline care plan on the electronic medical record. The MDS nurse said she thought the baseline care plan was initiated within the first 48 hours. The MDS nurse said the floor nurse, ADON, or DON, was responsible for initiating the baseline care plan. The MDS nurse said all the basics of care were on the baseline care plan, such as ADLs (eating, dressing), how the resident communicates, primary language, allergies, initial goals for facility and discharge plan, oxygen, CPAP, isolation, cognition, bowel and bladder, psychotropic medications, pain, diabetic, dialysis, terminal, and safety risk. The MDS nurse said the baseline care plan paints a picture on how to care for the residents. The MDS nurse said the nurse or staff may not know the right course of care on how to care for the resident. The nurse, ADON and DON, were responsible for following up to make sure it was completed in a timely manner. During an interview on 8/12/2026 at 11:25 AM, ADON A said the charge nurse initiates the baseline care plan. ADON A said the baseline care plan was an assessment. ADON A and the DON follow up on the care plan and sometime initiate them. ADON A said Resident #68 did not have a baseline care plan. ADON A said the baseline care plan should be initiated upon admission. ADON A said if the baseline care plan was not initiated, it could cause a lack of continuity of care. ADON A said Resident #68 was at the facility for respite then returned for admission. During an interview on 8/12/2026 at 11:45 AM, the DON said the nurse initiates the baseline care plan. The DON said Resident #68 does not have a baseline care plan. The DON said Resident #68 was at the facility for respite care then discharged and readmitted on [DATE]. The DON said his baseline care plan should have been completed within 48 hours of readmission. The DON said the charge nurse was responsible for initiation, but a Registered Nurse had to sign off. The DON said not having the baseline care plan could affect the resident's care. During an interview on 8/12/2026 at 12:03 PM, the ADM said the IDT team would be responsible for the baseline care plan. The ADM said the nursing staff initiated the baseline care plan and the IDT reviews and updates. The ADM said he was not sure how it works with Hospice. The ADM said he had only been at the facility for a month. The ADM said without the baseline care plan, the staff would not know if the residents were improving or declining. Review of a facility policy titled Care Plans-Baseline revised on March 2022, indicated .A baseline plan of care to meet the resident's immediate health and safety needs to be developed for each resident within forty-eight hours of admission.Policy Interpretation and Implementation.1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident.a. initial goals based on admission orders.b. physician orders.dietary orders.therapy services.social services.2. The baseline care plan is used until the staff can conduct the comprehensive assessment.3. A comprehensive care plan may be used in place of a baseline care plan.4. The resident and/or representative are provided a written summary of the baseline care plan.5. Provision of the summary to the resident and/or resident representative is documented in the clinical record.

Based on observation, record review and interview, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 18 residents reviewed for care plans, (Resident #1, #4, and #47). 1.Resident #1 was not care planned for his history of Urinary Tract Infections (bacterial infection in any part of the urinary system), encephalopathy (disease, damage, or malfunction of the brain that alters how it works), hospitalizations, and sepsis (the body has an extreme runaway immune response to an infection). 2.Resident #4 was not care planned for the wound to her ear or her foot. She was not care planned for the surgical wound to her chest. 3.The facility did not ensure Resident #47's care plan had specific triggers for his diagnosis of post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Resident #47 had a history of trauma. These failures could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. 1.Record review of the face sheet dated 8/11/26 indicated Resident #1 was a 59-year- old male that admitted [DATE] and readmitted [DATE]. Record review of the physician's orders dated 8/11/26 indicated Resident #1 had diagnoses that included: Cellulitis (a potentially serious bacterial skin infection affecting the deep layers of skin and subcutaneous tissues), Type 2 Diabetes (the body resists insulin or does not make enough of it), Peripheral Vascular Disease (narrows or blocks blood vessels outside of the heart), Transient Ischemic attack (a mini-stroke, when blood flow to a part of the brain stops for a short time), and sepsis (a life-threatening medical emergency that happens when the body has an extreme, runaway immune response to an infection). Record review of the Quarterly MDS dated [DATE] indicated Resident #1 had adequate hearing, clear speech, understood others, and was understood by others. He had a BIMS score of 10 indicating moderate cognitive impairment. Record review of the care plan with a revision date of 3/10/26 indicated Resident #1 was on Enhanced Barrier Precautions and he had a venous/stasis ulcer of the left shin related to peripheral vascular disease. He had cellulitis of the left lower extremity. The care plan indicated he had impaired cognitive function or impaired thought processes related to a history of TIAs causing memory loss and impaired decision making. Resident #1 had Diabetes Mellitus. The care plan did not address his history of UTIs, sepsis, Encephalopathy, or hospitalizations. Record Review of a physician's progress note dated 6/2/26 for a hospital recapitulation indicated Resident #1 had been in the hospital for acute encephalopathy. The physician's note indicated he had been in the hospital 4/8/26-4/11/26 for sepsis related to a UTI. Resident #1 continued to decline and he was sent back to the hospital on 4/12/26 due to sepsis from cellulitis and acute kidney failure. Record review of a physician's progress note dated 5/5/26 indicated Resident #1 was readmitted from the hospital with diagnoses that included hypoglycemia (blood glucose was too low) and acute encephalopathy. 2. Record review of the face sheet dated 8/11/26 indicated Resident #4 was a [AGE] year-old female that admitted [DATE]. Record review of the physician's orders dated 8/11/26 indicated Resident #4 had diagnoses that included: Type 2 Diabetes Mellitus with unspecified complications (the body resists insulin or does not make enough of it causing sugar to build up in the blood, with unmanaged complications stemming from high blood sugar), severe protein-calorie malnutrition (major lack of food, protein, and energy), and peripheral vascular disease (narrowed or blocks vessels outside of the heart). The physician's orders indicated: 6/12/26 Wound – sternum per open heart surgery. Remove old dressing, cleanse with vashe cleanser, pat to dry, apply 4 x 4 gauze soaked in 1/4 strength Daikins solution then cover with silicone dressing daily until resolved. Every 24 hours as needed. Change if dressing becomes soiled as needed. 7/7/26 Cleanse wound to right medial forefoot with normal saline/generic wound cleanser, pat dry. Apply hydrogel with silver, then cover with gauze dressing, daily until resolved, every day shift. 7/9/26 cleanse pressure ulcer to left ear with generic wound cleanser, pat dry. Apply hydrogel with silver to wound bed, cover with gauze dressing daily until resolved. Record review of the admission MDS dated [DATE] indicated Resident #4 had minimal difficulty hearing and clear speech. She was understood by others and usually understood others. Resident #4 had a BIMS score of 10 indicating moderately impaired cognition. The MDS indicated she was dependent on staff for personal hygiene and did not have any pressure wounds. Record review of the care plan with a revision date of 6/10/26 indicated Resident #4 had an ADL self-care performance deficit and was dependent on staff for dressing, bathing/showering, toileting, and personal hygiene. The care plan indicated she had Peripheral Vascular Disease, protein-calorie malnutrition, and had confusion at times. She also had the potential for pressure ulcer development. The care plan did not address the surgical wound on her chest, the wound on her right foot, or the wound on her ear. During an observation and interview on 8/10/26 at 10:23 AM, Resident #4 was in bed. She had water on her bed side table. She said staff was good to her and the food was okay. Her low loss air mattress was set at 280. Two offloading boots (soft boots for protection of the feet) were on the floor. A wedge positioning pillow was near the end of the bed. She said she did not know if she had any wounds but she needed to get to work. During an observation and interview on 8/10/26 at 10:28 AM, Resident #1 was sitting outside with other residents and staff. He said staff was good to him and the food was good. During an interview on 8/11/2026 at 9:00 AM, the MDS nurse said Resident #4 was not care planned for her surgical wound to her chest, the wound on her foot or her ear. She said it was the responsibility of the Treatment Nurse/ADON B to care plan any wounds. She said the DON would oversee all care plans. She said it was important for any type of wounds to be on the care plan, because all staff needed to know the wounds were there, how to treat the wound, monitor the wound, and follow the physician's orders to heal the wound. During an interview on 8/11/2026 at 11:03 AM, the MDS nurse said Resident #1 was not care planned for his UTIs, sepsis, encephalopathy, or hospitalizations. She said all of those things should have been in the care plan so that all staff knew of his history so they could monitor for, and try to prevent illness or hospitalizations. The MDS nurse said staff needed to know about UTIs, sepsis, encephalopathy, and hospitalizations to monitor the resident. She said any reoccurring problems should always be care planned and Resident #1 had had several UTIs and acute hospitalizations. He had a history of sepsis and encephalopathy. During an interview on 8/11/2026 at 1:09 PM, LVN C said Resident #1 was in and out of the hospital and had encephalopathy his last hospital visit. She said he had frequent UTIs, and had sepsis. She said he should have been care planned for his recurrent UTIs, sepsis, encephalopathy, and his hospitalizations because anyone providing care for him would need to know that information to know what to look for and what was going on with the resident. It was important to monitor for a change of condition and his past medical history, to monitor him and follow MD orders. She said Resident #4 should have been care planned for her surgical wound and any other wounds for the same reasons, to properly care for the residents. During an interview on 8/12/2026 at 8:04 AM, the MDS nurse said the UTI and encephalopathy for Resident #1 should have been care planned by ADON A because she was the Infection Preventionist now. For the surgical wound or any wounds/skin conditions ADON B should have care planned it, because she was the treatment nurse. The DON was who double-checked that the care plans were accurate and up to date. The MDS nurse said if a resident triggered for being at risk for pressure ulcers, she would care plan that. She said she did the comprehensive care plan based on the causes, like ADLs, bowel and bladder. She said if the MDS showed pressure wounds or skin conditions, she would not care plan that because clinical/the nurses did that. The DON made sure she did everything she was supposed to on the comprehensive care plans. During an interview on 8/12/2026 at 8:39 AM, ADON A said she was new in the role of doing care plans. She had only been doing them about a month. She said Resident #1 should have been care planned for his hospitalizations, encephalopathy, UTI, and sepsis or any history of those things. She said she was not responsible for care planning skin conditions or wounds unless that resident was on an antibiotic. She said ADON B was responsible for that. During a telephone interview on 8/12/2026 at 9:33 AM, ADON B said she was responsible for care planning any new wounds on a resident. She said the MDS nurse should have care planned Resident #4 for her surgical wound because she admitted with that. ADON B said she was responsible for care planning the wound on Resident #4's ear and the wound on her foot. She said she had forgotten to do it. She said she was not responsible for care planning Resident #1's hospitalizations, encephalopathy, UTIs or sepsis. During an interview on 8/12/2026 at 10:18 AM, LVN D said care plans were the responsibility of the MDS nurse and the DON. She said Resident #4 should have been care planned for her surgical wound, the wound on her foot, and the wound on her ear. She said care planning those things was important for all staff to know to watch for infection, maintain hygiene and health and abide by the Enhanced Barrier Precautions. She said Resident #1 should have been care planned for his history of UTIs, sepsis, hospitalizations, and encephalopathy so that staff could monitor to try to prevent any of those things from happening again. During an interview on 8/12/2026 at 10:35 AM, the DON said Resident #4 should have been care planned for her surgical wound by the MDS nurse because she admitted with it. She said ADON B should have care planned the wound on Resident #4's ear and the wound on her foot. ADON A should have care planned Resident #1 for his encephalopathy, UTI, Sepsis, hospitalizations. She said it was important for all those things to be care planned so staff would know and could monitor for signs and symptoms. During an interview on 08/12/2026 at 10:45 AM, the Administrator said ADON B was responsible for care planning Resident #4 for her surgical wound, wound on her foot, and wound on her ear. Care planning was important for proper care of the wounds, monitoring wounds and preventing infection. He said he did not know who was responsible for care planning Resident #1's UTIs, sepsis, encephalopathy, and numerous hospitalizations but those things should have been care planned for proper care and the best outcome for Resident #1. 3. Record review of the face sheet, dated 06/18/26, reflected Resident #47 was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis including Post Traumatic Stress Disorder (mental health condition that can develop after you experience or witness a terrifying or life-threatening event), End Stage Renal Disease (the final stage of long-term kidney damage), Adjustment Disorder (an emotional or behavioral reaction to a stressful life event such as a job loss, divorce, or illness that occurs within three months of the event). Record review of Resident #47's diagnosis sheet indicated that Resident #47 had an active diagnosis of post-traumatic stress disorder on 7/28/2026. Record review of the quarterly MDS assessment, dated 07/27/26, reflected Resident #47 had clear speech, was understood by others, and was able to understand others. Resident #47 had a BIMS score of 13, which indicated intact cognition. The MDS reflected Resident #47 was not coded for post-traumatic stress disorder as the quarterly MDS was completed the day before his post-traumatic stress disorder was recorded. Record review of Resident #47's most recent comprehensive care plan reflected no care plan was in place to address Resident #47's post-traumatic stress disorder. During an interview on 08/12/2026 at 10:47 a.m. the Social Worker said that she was responsible to ensure that residents with Post Traumatic Stress Disorder have their specific stress documented into their care plan. She said that if a resident did not have their traumatic event documented in their care plan then other staff may not be aware of their past trauma. She said that residents could potentially be exposed to something to trigger their past trauma. She said that Resident #47's care plan was not updated due to her error. During an interview on 08/12/2026 at 11:18 a.m. the Director of Nurses said that Resident #47's care plan should document their post-traumatic stress disorder and what specific triggers they had. She said that residents could be placed at risk as facility staff would not be aware of what could trigger Resident #47's past trauma. She said it was the responsibility of the Social Worker to ensure that residents with post-traumatic stress had it documented in their care plan. During an interview on 08/12/2026 at 12:05 p.m. the Administrator said that residents with post traumatic stress disorder should have it documented on their care plan. He said that residents could be placed at risk of triggering their past trauma if staff were unaware of what trauma they had. Record review of Care Plans, Comprehensive Person-Centered Policy, dated March 2022 indicated: Policy Statement 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. 1.The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. 7.The comprehensive, person-centered care plan: a.includes measurable objectives and timeframes; b.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including. (3)which professional services are responsible for each element of care. e.reflects currently recognized standards of practice for problem areas and conditions. 9.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10.When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12.The interdisciplinary team reviews and updates the care plan: a.when there has been a significant change in the resident's condition; b.when the desired outcome is not bet; c.when the resident has been readmitted to the facility from a hospital stay; and d.at least quarterly, in conjunction with the required quarterly MDS assessment.

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 personal hygiene for 1 of 6 residents reviewed for ADLs (Resident #68). The facility failed to provide change of clothing for Resident #68 on 8/11/2026 and 8/12/2026. This failure could place residents who required assistance from staff for personal hygiene at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 08/11/2026 indicated Resident #68 was an [AGE] year old male who was admitted on [DATE] with diagnosis including senile degeneration of brain (a progressive neurodegenerative disorder that primarily affects memory, thinking, and behavior, and is the most common cause of dementia), anxiety (an emotion characterized an unpleasant state of inner turmoil and feelings of dread), hypertension (a common condition where the force of blood against the artery walls is consistently too high), and benign prostatic hyperplasia (an enlarged prostate). Record review of Resident #68's admission MDS indicated it had not been completed at the time of inspection completion on 8/12/2026. Record review of a care plan initiated on 8/4/2026 while on respite, indicated Resident #68 not have a care plan for activities of daily living. Record review of progress notes from 8/10/2026-8/12/2026 did not indicate any refusals for clothing changes by Resident #68. During an observation on 8/10/2026 at 12:26 PM, Resident #68 was sitting up in wheelchair wearing a red shirt and had a blanket. During an observation on 8/11/2026 at 8:50 AM, Resident #68 was observed sitting in the front of the nurse station wearing a red shirt and covered with a blanket. During an observation on 8/11/2026 at 2:30 PM, Resident #68 was observed wearing a red shirt and was covered up with a blanket. During an observation on 8/12/2026 at 8:56 AM, Resident #68 was observed lying in bed. Resident #68 remained in the same clothes he had on 8/10/2026. Resident #68 was wearing a red shirt and was covered up in a blanket. Resident #68 was unable to be interviewed due to decline in health status and transitioning. During an interview on 8/12/2026 at 9:44 AM, Hospice CNA H said Resident #68 had been on hospice services for about 2 months. Hospice CNA H said Resident #68 was actively transitioning (refers to the final phase of life when the body gradually begins to shut down, signaling that death was likely within hours or a few days) and was being provided comfort measures. Hospice CNA H said she had given the resident a shower on Monday 8/10/2026. Hospice CNA H said she was waiting on the family to determine if they wanted her to administer him a bed bath. Hospice CNA H said Resident #68 was in the same clothes she placed on him on Monday. Hospice CNA H said she would have expected Resident #68 to be in different clothes. During an interview on 8/12/2026 at 10:17 AM, CNA G said 8/9/2026 was first day taking care of Resident #68. CNA G said Resident #68 was dependent (refers to a person or condition that relies on another for support or care). CNA G said Resident #68 could not dress or change himself. CNA G said she changed Resident #68 this morning and got him comfortable in bed at 8:45 AM. CNA G said she did not know he had clothes until she found a duffle bag with clothes located in his closet. CNA G said she did not realize he had clothing in there. CNA G said on Sunday, she had changed his clothes and got a t-shirt from the laundry. CNA G said Resident #68's clothes should be changed daily and if the resident's clothes were soiled. CNA G said it was important to change Resident #68's clothes to keep him clean and was about his hygiene. CNA G said the CNAs were responsible for changing the resident clothes. CNA G said she charts on ADLs. CNA G said it could be a dignity issue if a resident remained in the same clothing. During an interview on 8/12/2026 at 10:35 AM, LVN D said Resident #68 was dependent with care and required assistance with all ADLS such as bathing, dressing, and meals. LVN D said Resident #68 was currently on hospice care. LVN D said the facility staff were still responsible for ensuring Resident #68 was clean, changing his clothing, and repositioned. LVN D said Resident #68 had clothes at the facility. LVN D said Resident #68's clothing was in his dresser. LVN D said no one had changed resident since 8/10/2026. LVN D said the CNAs or the nurses were responsible for changing the residents' clothes. LVN D said Resident #68 did not refuse to change his clothes. LVN D said she did not know why Resident #68 was still in the same clothes. LVN D said she would have expected resident to have been changed. LVN D said even if a resident did not have clothes, there are extra clothes at the facility. LVN D said it could make a resident feel unclean, embarrassed and could be a dignity issue if his clothes were not changed. During an interview on 8/12/2026 at 11:15 AM, ADON A said she expected the staff to change Resident #68's clothing at least daily and if soiled. ADON A said Resident #68 has clothing in his room. ADON A said the charge nurse and the aides should be the ones changing the resident. ADON A said not changing a resident's clothing could cause skin issues and dignity issues. ADON A said Resident #68 was on Hospice care. ADON A said the facility staff was responsible for bathing and changing resident's clothing even if the resident was on Hospice care. During an interview on 8/12/2026 at 11:45 AM, the DON said she would expect Resident #68's clothes to be changed. The DON said Resident #68's clothing should be changed following a shower and at bedtime. The DON said Resident #68 had clothes in his room. The DON said it could affect the dignity of the resident if his clothes were not changed. The DON said all nursing staff (nurse, aides, hospice staff) were responsible for changing the resident clothes. The DON said the facility was responsible and Hospice was an addition to their care. During an interview on 8/12/2026 at 12:03 PM, the ADM said Resident #68 was at the facility for Hospice care. The ADM said he expected Resident #68 to be changed and not be in the same clothes. The ADM said Hospice assisted the facility with Resident #68's care. The ADM said the charge nurse was responsible for ensuring the resident was changed. The ADM said not changing clothing for Resident #68 could make him feel unclean. Record review of a facility policy titled Activities of Daily Living (ADL), Supporting revised February 2025 indicated .Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living. Policy Interpretation and Implementation.1. Resident will be provided with care, treatment, and services to ensure.a. the existence of clinical diagnosis.b. Unavoidable decline may occur if he or she.a. a natural progression of a debilitating disease with known functional decline.5. A resident's ability to perform ADLs will be measured using clinical tools.Functional decline or improvement will be evaluated in reference to the assessment.f. Dependent: If a helper does all of the effort.6. Interventions to improve or minimize a resident's functional abilities will be in accordance with the residents needs, preferences, stated goals and recognized standards of practice.

Based on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, and dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 5 residents (Residents #31 and #35) reviewed for pharmacy services. 1. The facility failed to ensure Resident #31 received her scheduled tramadol (pain medication) on 08/08/26 (p.m. dose), 08/08/26 (a.m. and p.m. dose), 08/09/26 (a.m. and p.m. dose), and 08/10/26 (a.m. and p.m. dose). 2. The facility failed to ensure Resident #35 received the correct dosage of cyanocobalamin (Vitamin B-12) as ordered by the physician on 08/11/26. These failures could place residents at risk for decreased quality of life, uncontrolled pain, or non-therapeutic medication levels. The findings included: 1. Record review of the face sheet, dated 08/11/26, reflected Resident #31 was a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of pain, unspecified and colon cancer. Record review of the annual MDS assessment, dated 04/24/26, reflected Resident #31 had clear speech, was usually understood by staff, and was usually able to understand others. She had a BIMS score of 5, which indicated severe cognitive impairment. The MDS reflected Resident #31 received scheduled pain medication and PRN pain medication. Resident #31 indicated she had occasional pain that rarely interfered with sleep or therapy. Her pain occasionally limited her day-to-day activities and was rated as a 3 on the zero to ten pain scale. Record review of the comprehensive care plan, dated 10/26/25, reflected Resident #31 had acute and chronic pain related to generalized discomfort. The interventions included: administer pain medication as ordered and monitor for verbal/nonverbal indicators of pain or discomfort. Record review of order summary report, dated 08/11/26, reflected Resident #31 had an order, which started on 07/23/26, for tramadol 50 mg - give one tablet by mouth twice a day for pain in unspecified knee. Record review of Resident #31's MAR, dated August 2026, reflected the following:1. On 08/08/26, the p.m. dose of tramadol 50 mg was not given; pain level was documented at a zero.2. On 08/09/26, the a.m. dose and p.m. dose of tramadol 50 mg was not given; pain level was documented at a seven and PRN Tylenol was given with effective results.3. On 08/10/26, the a.m. dose and p.m. dose of tramadol 50 mg was not given; pain level was documented at a zero. During an observation and interview on 08/10/26 at 9:59 a.m., Resident #31 was sitting at the dining room table with her head back and eyes closed. Her face was relaxed. She denied any complaints of pain or discomfort and was unable to remember what medications she usually took. She was unable to answer questions appropriately related to her cognition. During an observation and interview on 08/11/26 at 9:48 a.m., LVN E pulled a tramadol 50 mg tablet from the emergency kit with the DON as a witness. LVN E stated she had to call the pharmacy to obtain a code, in order to access the medication from the emergency kit. LVN E took the tramadol 50 mg tablet to her medication cart, verified the order on the MAR, and administered the pill to Resident #31. Resident #31 was sitting at the dining room table, with her head laid down and eyes closed. She easily responded and her face appeared relaxed. Resident #31 denied any complaints of pain. LVN E stated Resident #31 had been out of her pain medication for a few days, but they were able to pull the medication from the emergency kit. LVN E stated Resident #31's tramadol order recently changed to routine and the facility was having troubling getting the medication re-ordered from the pharmacy. During an attempted telephone interview on 08/11/26 at 3:36 p.m. with LVN F there was no response. A brief message was left with a call back number, and the call was not returned upon exit of the facility. During an interview on 08/12/26 at 11:04 a.m., LVN E stated she administered Resident #31's pain medication late on 08/10/26 when she realized she could have pulled it from the emergency kit. She stated she was unaware tramadol was available in the emergency kit. LVN E stated on 08/10/26, she had already documented the pill as not administered and was unsure if she was able to change the documentation. She stated it was important to ensure medications were given and signed out as given to prevent accidental overdose and to maintain Resident #31's pain at an acceptable pain level. LVN E stated Resident #31 had no increased verbal or nonverbal indicators of pain. She stated Resident #31 had no changes in behaviors or decline in functioning from not getting her pain medications. During an interview on 08/12/26 at 11:20 a.m., the DON stated Resident #31's tramadol was not administered over the weekend. The DON stated she reviewed the 24-hour report sheet on 08/10/26 and realized that the medication was out and had not been given out of the emergency kit. The DON stated she explained to the nurse's tramadol was available in the emergency kit and instructed them to pull the tramadol out of the emergency kit. The DON stated she was unsure if LVN E administered Resident #31's medication on 08/10/26 but was sure Resident #31 did not receive the medication on 08/08/26 and 08/09/26. The emergency kit access logs were requested. Record review of the transaction by employee and witness logs, dated 08/10/26 - 08/11/26, reflected tramadol 50 mg was not taken from the emergency kit on 08/10/26. 2. Record review of the face sheet, dated 08/11/26, reflected Resident #35 was a [AGE] year old female who admitted to the facility on [DATE], with a diagnosis of vitamin deficiency, unspecified. Record review of the quarterly MDS assessment, dated 07/03/26, reflected Resident #35 had clear speech, was understood by others, and was able to understand others. She had a BIMS score of 10, which indicated moderately impaired cognition. Record review of the comprehensive care plan, dated 05/29/26, reflected Resident #35 was susceptible to infection due to nutritional deficiencies. The interventions included administering oral nutritional supplements as necessary. Record review of the order summary report, dated 08/11/26, reflected Resident #35 had an order, which started on 05/19/26 for cyanocobalamin 1000 mcg - give two tablets by mouth in the morning related to vitamin deficiency. Record review of Resident #35's MAR, dated August 2026, reflected cyanocobalamin 1000 mcg - give two tablet by mouth in morning was given daily. During an observation and interview on 08/11/26 at 8:16 a.m., LVN C prepared Resident #35's medications for administration. She placed two vitamin B-12 500 mcg tablets into the medication cup. LVN C stated Resident #35's order was for 1,000 mcg of vitamin B-12 so she used two 500 mcg tablets to equal 1,000 mcg. Resident #35 took the medications. During an interview on 08/12/26 at 11:15 a.m., LVN C stated she did not realize Resident #35's vitamin B-12 order was for 1,000 mcg - give two tablets by mouth every morning. LVN C stated she believed the order was to give two 500 mcg tablets to equal 1,000 mcg. She stated the order should have been clarified with the physician before it was given. She stated it was important to ensure the correct dosage of medication was given to ensure the residents were getting the supplementation they needed to prevent vitamin deficiencies. During an interview on 08/12/26 at 12:52 p.m., the DON stated she expected the nursing staff to verify the medications dosage before it was given. The DON stated if there were discrepancies with the order dosage, she expected the nurses to ensure the order was clarified with the physician before it was given. She stated the charge nurse was responsible for monitoring to ensure medications were given correctly. The DON stated it was important to ensure medications were given correctly to maintain therapeutic levels of the medications. The DON stated she expected the charge nurse to check the emergency kit for a medication before marking it as unavailable or not administered. She stated the charge nurse was responsible for making sure the medications were available and given. The DON stated she was responsible for making sure the nurses had access to the emergency kit. She stated it was important to ensure pain medications were available and administered for pain management, making sure the plan of care was followed, and the residents' needs were being met. The DON stated Resident #31 had no verbal/non-verbal indicators of pain or discomfort. It had not been reported that Resident #35 had any changes in condition or behaviors. During an interview on 08/12/26 at 1:00 p.m., the Administrator stated he expected the proper medication dosage to have been given. He stated he expected orders to be clear or clarified as needed for clarity. The Administrator stated nurse management was responsible for monitoring to ensure medications were given correctly. He stated it was important to ensure medications were given correctly for the residents' overall health. The Administrator stated he expected the resident to receive their medications as available. He stated he expected the staff to ensure medications were available in the emergency kit. He stated the nurse management was responsible for monitoring to ensure medications were available and given. He stated it was important to ensure medications were given, especially pain medications, to maintain the residents' best quality of life possible. Record review of the Medication Shortages/Unavailable Medication policy, undated, reflected When medications are not received or are unavailable for the customers, the licensed nurse will urgently initiate action in cooperation with the attending physician and the pharmacy provider. If a medication shortage is noted at the time of medication administration, the licensed nurse or certified medication assistant must immediately initiate action to obtain the medication and not wait until the med pass is completed. If the next available delivery results in a delay or missed dose in the customer's medications schedule, take the medication from the emergency stock supply to administer the dose. Record review of the Administering Medication policy, dated April 2019, reflected Medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders. The individual administering the medications checks the label three times to verify the . Right dosage. before giving the medication.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 1 of 18 residents (Resident #4) reviewed for infection control practices. 1. The facility failed to ensure ADON A changed her gloves and performed hand hygiene appropriately after performing wound care on Resident #4, who was on Enhanced Barrier Precautions. 2. The facility failed to ensure ADON A did not touch Resident #4's offloading boots (soft pillow like boots), legs, pillow, and her sheet with the same gloves used for wound care. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections. Record review of Resident #4's face sheet, dated 8/11/26, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Record review of Resident #4's physician's orders, dated 8/11/26, indicated Resident #4 had diagnoses which included: Type 2 Diabetes Mellitus with unspecified complications (the body resists insulin or does not make enough of it causing sugar to build up in the blood, with unmanaged complications stemming from high blood sugar), severe protein-calorie malnutrition (major lack of food, protein, and energy), and peripheral vascular disease (narrowed or blocks vessels outside of the heart). The physician's orders indicated: 7/7/26 Cleanse wound to right medial forefoot with normal saline/generic wound cleanser, pat dry. Apply hydrogel with silver, then cover with gauze dressing, daily until resolved, every day shift. Record review of Resident #4's admission MDS, dated [DATE], indicated Resident #4 had minimal difficulty hearing and clear speech. She was understood by others and usually understood others. Resident #4 had a BIMS score of 10, which indicated moderately impaired cognition. She was dependent on staff for personal hygiene and did not have any pressure wounds. Record review of Resident #4's care plan, with a revision date of 6/10/26, indicated Resident #4 had an ADL self-care performance deficit and was dependent on staff for dressing, bathing/showering, toileting, and personal hygiene. The care plan indicated she had Peripheral Vascular Disease, protein-calorie malnutrition, and had confusion at times. She also had the potential for pressure ulcer development. The care plan did not indicate she had a wound on her right foot. During an observation and interview on 8/10/26 at 10:23 AM, Resident #4 was in bed. She had water on her bedside table. She said staff were good to her and the food was okay. Her low loss air mattress was set at 280. Two offloading boots were on the floor. A wedge positioning pillow was near the end of the bed. She said she did not know if she had any wounds but she needed to get to work. During an observation on 8/11/26 at 8:19 AM, Resident #4 was in bed with the head of the bed up approximately 40 degrees. Staff was feeding her breakfast. During an observation on 8/11/26 at 1:52 PM, Resident #4 was lying in bed. She had offloading boots on both feet and a pillow between her knees. Her low loss air mattress was set at 120. She denied pain. ADON A donned (put on) proper personal protection equipment for Resident #4's Enhanced Barrier Precautions and performed wound care to Resident #4's foot, and without changing her gloves or sanitizing her hands she touched the offloading boots, Resident #4's legs, pillow, and her sheet. During an interview on 8/11/26 at 2:02 PM, ADON A said I knew better than that. She said touching items with dirty gloves could cause cross-contamination and infection to both residents and staff. She said she should have changed her gloves and sanitized her hands before touching anything. During an interview on 8/12/26 at 10:18 AM, LVN D said staff should change their gloves and sanitize their hands anytime their gloves were considered dirty. She said contact with an open wound would mean gloves were dirty and should be changed before touching anything clean to prevent infection and cross-contamination. During an interview on 8/12/26 at 10:35 AM, the DON said gloves should always be changed between clean and dirty procedures. She said an open wound would be considered dirty. Staff not changing their gloves and sanitizing their hands posed a risk of infection and cross-contamination to staff and residents. During an interview on 8/12/26 at 10:45 AM, the Administrator said anytime a task was performed on a resident, the gloves would be considered dirty and would need to be changed. He said after performing wound care staff would have to change their gloves and sanitize their hands before touching anything clean or it could cause worsening to the wound, infection to staff and residents, and could risk the overall health of staff and residents. Record review of a Wound Care Policy, dated July 2024, provided by the DON indicated: PurposeThe purpose of this procedure is to provide guidelines for the care of wounds to promote healing.Steps in the Procedure6. Put on gloves. Gown as indicated based on Enhanced Barrier Precautions.10. Wear gloves when physically touching the wound.12. Apply treatments as indicated .13. Dress wound.16. Remove disposable gloves and discard into designated container. Wash and dry hands thoroughly.17. Reposition the bed covers. Make the resident comfortable. Use supportive devices as instructed. Record review of an Infection Control Program-Introduction, dated February 2026, provided by the DON indicated: PurposeThe Infection Prevention and Control Program (IPCP) ensure the facility maintains a safe, sanitary, and organized system to prevent transmission of infectious diseases, reduce healthcare-associated infections, and comply with federal and state regulatory requirements (F880).

Based on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility failed to ensure a certified Activity Directory was employed for the facility. This failure could place residents at risk of not receiving a program of activities that met their assessed activity needs.Findings included: Record review of the Activity Director's employment file reflected that the Activity Director did not have a certification. During an interview on 8/12/2026 at 9:01 a.m. the Administrator stated that his Activity Director was not certified and had not received approved training by the state of Texas. He said that he did not hire the Activity Director as they were hired prior to him being employed. He said that they were in the process of paying for their schooling but all the schools they found were expensive. He said that they recently found an online school with a program that was affordable and will be enrolling their Activity Director in this program. During an interview on 8/12/2026 at 9:18 a.m. the Regional Nurse said that the previous Administrator hired the current Activities Director. She said that she did not know why she was hired without her certification. She said that the Activity Director was not in a training course to become certified and she will look into what was being done to fix the situation. During an interview on 8/12/2026 at 9:32 a.m. Activity Director, said that she had not taken the Activity Director certification training. She said that she was notified as of today that corporate would get her enrolled into a class. She said the previous Administrator hired her as the Activity Director after the previous Activity Director quit. She said she was the Assistant Activity Director then and she stepped up into the position. She said that she has been working as the Activity Director since 2022. She said she would love to attend the training to be certified. During an interview on 8/12/2026 at 10:36 a.m. the Administrator said that there was not a specific policy stating that the facility requires that their Activity Director had their certification.

Based on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 7 (the park place hall) medication carts reviewed for storage of medications. The facility failed to ensure LVN A locked and secured the park place hall medication cart while not in use and unattended on 06/25/26. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications. Findings included: During an observation and interview on 06/25/2026 at 11:46 AM revealed LVN A left the park place medication cart unlocked and unattended in the hallway while she was in a resident's room. The park place medication cart lock was sticking out indicating it was unlocked and the cart was facing out toward the middle of the hallway while other staff and residents were in the hallway. LVN A said she was passing meds and was asked for assistance to help in a resident's room, and she just forgot to lock the cart. LVN A said she had left the park place medication cart unattended for approximately 3-4 minutes. LVN A said the failure ked to a risk for any residents getting into the cart, ingesting medications and harming themselves. During an interview on 06/25/26 at 3:45PM the ADON said the charge nurses were responsible for ensuring the medication carts were locked when the carts were not in use and the department head nurses completed rounds to ensure the medication carts were locked. The ADON said the failure placed led to the risk of medications getting in the hands of the residents and the residents consuming medications. During an interview on 06/25/26 at 3:56 PM the DON said the charge nurses were responsible for ensuring the medication carts were locked when the medication carts were not in use even if the carts were parked in a room. The DON said the failure led to the risk of a drug diversion, residents getting hold of medications, and ingesting which could be life threatening. During an interview on 06/25/26 at 4:06 PM the Administrator said she expected the medication carts to be locked at all times if not in use. The Administrator said the failure led to a risk for residents having access to medications and ingesting. Record review of the facility policy, revised February 2023, Medication Labeling and Storage indicated: Policy heading: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity, and light controls. Only authorized personnel have access to keys.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 21 residents (Resident #170) reviewed for supervision.The facility failed to ensure Resident #170 eloped (via foot) from the facility to a local energy service company (0.7 miles) on the night of 06/13/25 at 7:45 PM. Resident was found 4 1/2 hours later at 12:24 am on 6/14/25.The noncompliance was identified as PNC. The IJ began on 6/13/25 and ended on 6/14/25. The facility had corrected the noncompliance before the survey began.This failure could place residents at risk for injuries due to not receiving the appropriate level of supervisionFindings included:Record Review of profile sheet dated 6/24/25 at 12:20 p.m., indicated, Resident #170 was diagnosed with dementia without behavioral disturbance (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life).Record Review of Resident #1's care plan, dated on 06/13/25, indicated Resident #170 resided in the secure unit related to risk for elopement. The care plan goal included: Safety will be maintained, and resident will wander about unit without the occurrence of any injury through the next review date. The care plan interventions included: Activity Director to monitor/discuss activity preferences; Call by name when providing care, involve in care as much as possible; Explain procedures, using terms/gestures resident can understand-repeat PRN; Keep environment free of possible hazards and Monitor to assure resident safety.Record Review of observation detail report on Resident #170 dated on 6/13/25 at 0027 indicated, Resident #170 had a history of wandering prior to admission; resident exhibits wandering behavior; resident had (1) or more occasions attempted to exit or had exited the facility in a effort to wander away; resident follows others around, if someone exits the facility the resident will follow; resident had a medical diagnosis associated with confusion; resident experienced increased confusion, occurring with high risk factors; resident exhibits behavior typical boredom, (1) goes to door, turns doorknob, but does not exit (2) walks to window and gazes outside,(3) wanders into other resident or facility rooms to observe and or engage in conversation with other residents and or staff members, etc. The observation report indicated the potential interventions included the secure unit. The observation report indicated the safety awareness: resident recognized stop lights and signs; resident knew precautions when crossing the street; resident can state name; resident did not know the location of current residence; resident physical needs.Record Review of progress Note from LVN G dated 6/13/25 at 7:54 pm indicated, Resident #170, Resident up walking in common area adjusting well to surroundings makes needs known denies pain or discomfort.Record Review of Event report dated 6/13/25 at 10:30 pm indicated, resident was located approximately 1 mile from the facility at 0024; Possible contributing factors: Alzheimer's Disease, Dementia, and terminal illness; Unsettled relationships: Absence of personal contact with family/friends and does not adjust easily to change in routine; Inventions: Resident was taken back home with family.Record Review of a typed note by the Administrator dated on 6/13/25 at 10:30 pm indicated, Notifications were made to the medical director, Administrator, DON, Hospice company, LTC management team and family members. Record Review of the EMS report on Resident #170 on 6/14/25 at 0029 indicated, Resident #170 did not need treatment or transport. EMS released the resident to resident #170's family member.Record Review of progress note from RN H on 6/14/24 at 1:15 am indicated, Writer was notified by charge nurse at approximately 20:30 resident could not be located within secured unit, or facility. Facility grounds and surrounding areas searched. Unable to locate resident. Local police department contacted for assistance. Family and hospice company, MD contacted. Resident located off facility property at approx. 00:24. Head to toe assessment completed by local fire department with 0 injuries or skin concerns reported to writer. Resident ambulating, talking with 0 concerns visualized. Family along with local police department retuned resident to facility, family gathered medications and belongings and resident was discharged into family care at this time. Hospice and MD aware.Record review of provider self-reporting of LTC incident dated 6/14/25 at 12:52 pm indicated, this incident occurred on 6/13/25 at 8:30 pm regarding a missing Resident #170. The report indicated at approximately 2021 on June 13, 2025, the director of nursing notified the Administrator that a resident was unaccounted for and potentially missing from the facility. The Administrator immediately contacted the corporate team and instructed all departmental staff to return to the facility to assist in a coordinated search effort. The report indicated immediate facility actions taken elopement risks assessments were reviewed and updated; abuse and neglect in-services provided to all staff; elopement prevention and response in service training was conducted; Notification made: Administrator, DON resident's family, Hospice provider, Medical director, corporate oversight team and police notified. The report indicated a brief narrative of the incident: At approximately 2021 on June 13th, 2025, the Director of Nursing notified the Administrator that a resident was unaccounted for potentially missing from the facility. The Administrator immediately contacted corporate team and instructed all staff to return to the facility to assist in a coordinated search effort. A through room-by-room search of the building was conducted and confirmed the resident was not present within the facility. Immediately following staff conducted a search of the facility grounds and surrounding areas, law enforcement, the resident family and hospice team were notified at that time, at approximately 0050 on June 14th, 2025, the resident was found unharmed with no visible injuries or signs of distress. Upon medical clearance the resident was turned over to her family. At 0115 the family returned to the facility to retrieve the resident's personal belongings and formally discharged the resident into their care.Record Review of the facility investigation report undated, indicated, According to nursing staff, resident was last seen between 1925 -1945 on 6/13/2025 on Whisper Lane. Nurse stated that all meds were given after the evening meal and resident had gone to her room for the evening. At 2021, the DON contacted the administrator to Inform him that resident was missing, and staff had been unable to locate her for the previous 10-15 minutes. Administrator and DON immediately implemented elopement protocol for the building. The administrator and DON called in all department heads that live nearby into the building to help with the search efforts. At 2023, Administrator notified RDO (Regional Director of Operations) of missing resident and staff began a room by room sweep of the building and grounds immediately around the facility. At 2107, the administrator called Police Department Ref# 25-002512 and reported a missing resident. Concurrently, MD, family, and hospice were notified as well, and search efforts were expanded to nearby streets, residential areas and places of business. Police showed up shortly after 2115 to receive information related to the resident and to expand search efforts by employing Volunteer Fire Department. Roughly around 2140, an expanded search was being conducted further out from the nursing facility during this search the resident was located at 0024, 06/14/2025 at Energy Company. Resident was medically assessed by EMS services and found to have no injuries or adverse effects relating to the incident. On 6/14/2025 at 0045, EMS released resident to her family where she was transported back to the facility so family could pick up the remaining items from her stay. Resident was officially discharged from the facility on 6/14/2025 at 0115. Investigation Findings: The maintenance director checked all doors, alarms, and keypads at 2040 and found that all were closed, locked and functioning properly. With this information the facility can only speculate that the resident was able to exit Whisper Lane at the same time a visitor was entering/exiting Whisper Lane and was not aware that the resident was actually a resident and not a visitor herself. Immediate Actions Taken: Maintenance director checked all doors, alarms, and keypads at 2040: all functioned properly; Police were notified after resident was not located on facility grounds; MD, family and hospice were promptly notified of the missing resident; Fire Department located the resident at 0024: resident was medically assessed by EMS and released to family at 0045; Resident returned to facility with family to pick up remaining items and officially discharged home to family at 0115.During record review on 6/24/25 at 10:16 a.m., the facility completed elopement risks for all residents residing in the secure unit following this incident on 6/13/25.During record review on 6/24/25 at 10:46 a.m., the facility completed in services on abuse and reporting on 6/13/25; Elopement policy and prevention on 6/13/25; Nursing policy and Procedure and Door codes a secure unit safety on 6/14/25.During record Review on 6/24/25 at 10:57 a.m., Door/gate checkoffs dated May 2025 was reviewed by the Maintenance Director and Administrator. During record Review on 6/24/25 at 11:00 a.m., monthly and daily coded door inspection in-service was reviewed; this in-service was signed by the maintenance director on 6/16/25. The in-service objective: to ensure the safety and security of all residents by maintain fully functional coded exits and gates. All coded doors and gates must be checked daily for proper functioning and coded lock integrity. Additionally, codes must be changed out and tested monthly to mitigate risk of unauthorized exit; Responsibility of Maintenance Director: (1) perform a physical check of each listed door and gate to ensure close a lock securely (2) check door alarms and coded lock function to verify proper operation. (3) Document all daily door checks on the log sheet provided (4) change and test all coded door/gate locks once every month (5) immediately report and correct any malfunction or failure to lock/alarm (6) participate in quarterly safety meetings and submit log summaries to the Administrator.Record Review of the official police report was requested by the Administrator on 6/24/25 at 11:50 a.m., police report was not received prior to exit on 6/25/25.Record Review on 6/24/25 at 4:35 p.m., of the monthly/daily summary door and gate checkoff for the month of June 2025 indicated, daily checks on exit door, courtyard, courtyard gate, side door to laundry, dining south exit, Texas, Blvd. exit, Park ave exit and back nurse Exit were completed Monday thru Friday from 6/11/25 to 6/24/25. During a return phone call interview on 6/24/25 at Resident #170 RP stated on the night of June 13th her Resident#170 RP called her about 9 pm stating that Resident #170 was missing from the nursing home. Resident #170 RP stated her was notified by hospice company that was missing from the facility. Resident #170 RP stated she and her whole family went to go look for Resident#170. Resident #170 RP stated upon admission she was supposed to be in a locked unit. Resident #170 RP stated had memory issues. Resident #170 RP stated Resident #170 called her Mom and called her husband Pawpaw. Resident #170 RP stated when she arrived at the facility that no staff member at the facility could tell her what time her went missing. Resident #170 RP stated she was not sure where Resident #170 was found. Resident #170 RP stated she estimated to be gone from the facility for at least 5 to 6 hours. Resident #170 RP stated she was found by fire department trying to enter an unknown building. Resident #170 RP stated a police report had been filed but she did not have a copy of the report. Resident #170 RP stated when she was outside the nursing home and the police officer had gathered everyone at the facility and a staff member had told the police that he gave her medicine around 7:45 pm on that Friday (6/13/25). Resident #170 RP stated her had posted on her Facebook page that her had been missing. Resident #170 RP stated someone from Facebook had reached out to her and stating they believed to had seen her around 7 pm on that Friday night 6/13/25 but they did not know who was at the time until they seen the Facebook post online. Resident #170 RP stated the police told her that he had gotten conflicting stories from the nursing facility. Resident #170 RP stated was back at home following this incident. Resident #170 RP stated her (Resident #170) was set up for respite care in her home and was doing fine. During a returned phone call interview on 6/24/25 at 9:57 am., LVN G stated the last time he had seen the resident was around 7:45 pm on 6/13/25. LVN G stated shortly after he had seen the resident in the facility an aide in the secure unit had come and asked him if he had seen Resident #170. LVN G stated he had started looking for the resident and he could not locate the resident in the secure unit. LVN G stated he checked closets and residents' room and could not locate the resident. LVN G stated he called the DON and notified the DON of the resident missing. LVN G stated the DON got the search party going. LVN G stated staff continued looking for the residents while he stayed back with the other residents. LVN G stated at shift change he gave a report to the oncoming nurse about the elopement of Resident #170. LVN G stated after his shift, he stayed and talked to the police officer, DON, and Administrator. LVN G stated following his shift the resident had not been located. LVN G stated he was told after the resident was found by the police station that the resident did not have any injuries. LVN G stated he was told the resident was okay. LVN G stated staff was trained on elopement following this incident. LVN G stated the facility had changed a lot since this incident. LVN G stated family members who came to visit loved ones did not come and go freely on their own in the secure unit. LVN G stated the family members were let in and out of the secure unit by staff only. LVN G stated he worked the 2 pm to 10 pm shift on the day of this incident and he was the charge nurse in the secure unit.During an interview on 6/24/25 at 8:45 a.m., CNA F stated she was not sure what took place. CNA F stated she just noticed the resident was at the facility and then the resident went missing. CNA F stated she did not know how long the resident was missing. CNA F stated she did know where the resident was located at. CNA F stated the resident family took the resident back home when she was located on 6/14/25. CNA F stated she was not aware of the residents having any issues. CNA F stated she worked the 2 to 10 pm shift at the facility. CNA F stated she was informed that resident was missing when she came back from break. CNA F stated she did not remember what time she had taken her break. CNA F stated she had been employed at the facility for 6 months. CNA F stated she received training on what to do when a resident eloped from the facility. During an interview on 6/24/25 at 2:53 p.m., the Maintenance Director stated he a performed a physical check of each listed door and gate on 6/13/25 to ensure they closed and locked. The Maintenance Director stated he checked the door alarms and coded locks on 6/13/25 and had no issues. The Maintenance Director stated he tested all coded door/gate locks monthly. The maintenance Director stated he documented monthly door checks but since this elopement incident he documented daily door checks. The Maintenance Director stated he reported malfunction locks and alarms to the Administrator and corporate office. The Maintenance Director stated he submitted monthly summary logs to the Administrator and participated in quarterly safety meetings. The Maintenance Director stated he did not have any summary logs to provide for review. The Maintenance Director stated he was the Maintenance Director at the time of this incident. The Maintenance Director stated that he had been the Maintenance Director for 5 years. The Maintenance Director stated following this incident that the facility conducted in-services on door alarms and locks. During an interview on 6/24/25 at 3:10 p.m., the DON stated she was the DON at the time of this incident. The DON stated she got a phone call from the charge nurse stating they could not locate the resident in the facility. The DON stated she informed the Administrator that the resident was missing from the facility. The DON stated from the time she was notified to the time the resident was found it was about 4 hours. The DON stated the resident was found by the local fire department. The DON stated the resident was attempting to enter a closed business and that's how the resident was located. The DON stated she did not assess the resident and EMS reported to her that she did not have any injuries. The DON stated EMS stated the resident did not appear hungry or thirsty. The DON stated the police was notified. The DON stated interviews from staff member were collected by the Administrator and herself. The DON stated the facility changed the codes to the entrance. The DON stated since this incident families were escorted off and on the facility. The DON stated before this incident family were able to enter the facility because they had the codes to the facility. The DON stated the family, hospice and the medical director was notified of this incident. The DON stated after this incident the family brought the resident to the facility and gathered the rest of the resident's belonging. The DON stated the resident was residing in the secure unit at the time of the elopement. The DON stated the only assumption of how the resident was able to leave was that the resident exited the facility with a family member. The DON stated the resident was very mobile and looked young. The DON stated the facility was responsible was responsible for ensuring the residents did not elope from the facility. The DON stated the risk for elopement was injury and harm. The DON stated staff were in-serviced on elopement policy and procedures, but staff were not in service on exit seeking behaviors. During an interview on 6/24/25 at 3:43 p.m., the Administrator stated he was the Administrator at the time of this incident. The Administrator stated he had been the Administrator for 2 1/2 months. The Administrator stated he was notified by the DON via phone call. he stated he told the DON to go into policy and procedure and lock down the building. The Administrator stated he had department heads do an inside sweep of the building to search for the resident. The Administrator stated he was told the resident had been missing for 10 to 15 minutes. The Administrator stated the fire department found the resident near key energy services which was 100 yards from the police and fire department. The Administrator stated the resident did not have any injuries. The Administrator stated the polices was notified at 2107 on 6/13/25. The Administrator stated he received two written statements from staff on what happened. The Administrator stated he changed his door codes monthly. The Administrator stated he had daily monitoring on all door and access point. The Administrator stated since the elopement that he conducted daily rounds, and he checked the door and locks randomly. The Administrator stated he discussed safety in QAPI meetings. The Administrator stated he audible alarms on all the door if the keypad system was to go down, that the facility had a backup system in place of the keypad system. The Administrator stated after this elopement the resident discharged home. The Administrator stated the resident was residing in the secure unit at the time of this elopement. The Administrator stated he did not know how the resident was able to leave the secure unit. The Administrator stated all staff was responsible for ensuring the resident did not elope from the facility. The Administrator stated the family, medical director and ombudsman was notified of the elopement. The Administrator stated the risk for elopement was injury or harm. During a phone interview on 06/24/25 at 05:10 p.m., LVN A stated she worked the 10pm to -6 am shift 4 days on and 2 off. LVN A stated she had been employed at the facility for 8 months. LVN A stated she worked the night shift on that night of the elopement. LVN A stated when she got to work Resident #170 was gone already. LVN A stated when the resident was found that the DON called her about 12:30 AM and said the family wanted her medications and belongings and she gathered them and met family at the front door to give the belongings to the police officers. Stated she staff received a refresher of an in-service over elopement. LVN A stated she did not work the night before. he Stated they had a few different in-services over elopement including exit seeking behaviors. LVN A stated staff changed all the codes on the doors in the unit and the other doors to the facility. LVN A stated the 3 doors in the unit have a chime noise it makes when anyone enters or exits. LVN A stated no visitors have any of the codes and the staff have to allow them visitors in and out. During a phone interview on 6/24/25 at 5:11 pm CNA B stated she came in at 10 pm on 6/13/25 and she was notified that the resident was missing upon entering the facility. CNA B stated in-services was completed following this incident. CNA B stated in-services on elopement, abuse and neglect, door alarms. CNA B stated staff had changed all the codes to the building. CNA B stated the facility had alarms on the doors and windows. CNA B stated the facility upgraded the doors. CNA B stated family members and guest did not know the codes to the door. CNA B stated she worked the night shifts. CNA B stated she worked the 10 pm to 6 pm. stated she had been employed at the facility for 14 years. CNA B stated was a CNA. CNA B stated she worked in the secure unit. During an interview on 06/24/25 at 05:09 p.m., CNA C stated she worked the 2-10 pm shift normally. CNA C stated she had no idea how the resident got out of the facility. CNA C stated, You can't miss the resident because the resident hovers over you. CNA C stated she remembered staff serving and then the resident was helping staff pick up trays. CNA C stated staff took the trays back and the resident was around the desk. CNA C stated staff then laid a few residents down and Resident #170 was in the dining room. CNA C stated CNA F had asked her if she could go on lunch and she told CNA F, Yes. CNA C stated doing this time Resident #170 was at the nurse's desk. CNA C stated next, she went to lay another resident down (Resident#270) and Resident #170 was around the nurse's station. CNA C stated after she laid her down and upon coming out from Resident #270's room Resident #170 disappear. CNA C stated staff started looking by checking the rooms, opening bathrooms door and staff could not find Resident #170. CNA C stated the charge nurse (LVN G) called the DON. CNA C stated Resident #170 was at the facility when CNA F went to lunch. CNA C stated staff started looking for the resident before CNA F came back from break. CNA C stated when CNA F came back from break that, she helped staff look for the resident. CNA C stated to her knowledge, there were no family members at the facility when the resident disappeared. CNA C stated the aide CNA F had been gone to lunch when Resident #170 went missing and LVN G had not left the unit. Stated someone checked the windows in the secure unit. CNA C stated all 3 doors had a code to enter and exit. CNA C stated she received education on elopement, plan-to look in all room, notify the DON and notify the police. CNA C stated staff also went over if a resident was exit seeking and to keep your eye on the residents. CNA C stated Resident #170 never said she wanted to get out of the facility to her. CNA C stated the resident was only at the facility for respite for 5 days. CNA C stated it was usually 2 aides and 1 nurse or 1 nurse and 1 aide but mostly 3 staff in the secure unit. CNA C stated if a resident wanted or attempted to leave the facility that she would redirect the resident and keep an eye on the resident.During an interview on 06/24/25 at 05:30 p.m., CNA D stated she had been employed at the facility for over a year. CNA D stated she was not at the facility on the day of the elopement (6/13/25). CNA D stated she usually worked 10pm to 6am shift and most residents were asleep during her shift. CNA D stated she received education on the door code, keeping the doors locked, checking on the residents, elopement and exit seeking behaviors. CNA D stated if a resident was trying to exit seek staff were to watch the residents and redirect the residents. CNA D stated on the night shift that it was 1 nurse and 1 aide.During an interview on 06/24/25 at 05:34 p.m., RN E stated she worked PRN at the facility. RN E stated she never met Resident #170. RN E stated she was gone for over 2 weeks from the facility. RN E stated she received education on not letting anyone know the codes to the doors. RN E stated if a resident was to attempt to exit seek that she would redirect the resident and watch the resident closely. Record Review of the Elopement policy dated 12/2017 indicated, Policy: It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or grounds; Procedure: The following steps are to be followed when a resident leaves the home grounds without staff notification; Home staff will: search the home and grounds, send staff member(s) out to locate the resident, notify Administrator or on-call person immediately, if resident is not located, call the police for assistance; Charge nurse will: Notify responsible party(this may be done when the search is initiated), notify the resident physician, assess the resident on return to the home, document the time resident absence is noted, time of return, assessment of resident and notification of the physician and responsible party; complete incident report in the clinical software; follow-up charting for 24hours if no injuries: follow up charting on injuries until resolved; administrative/Supervisory staff will: determine if elopement is reportable to state regulatory agency, interview staff and obtain written statements. If resident was returned by outside personnel, obtain name, phone number and details with any information of where resident was found and under what circumstances the resident was found, establish a monitoring system for resident until flight risk is resolved determine what measures can be taken to prevent it from happening again, if elopement is reported, contact appropriate corporate personnel.The noncompliance was identified as PNC. The IJ began on 6/13/25 and ended on 6/14/25. The facility had corrected the noncompliance before the survey began.

Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to ensure the pulled pork was properly thawed before cooking.2. The facility failed to ensure the peas, sweet potato fries, cinnamon rolls, and an unknown type of breaded meat were dated and labeled.3. The facility failed to ensure the baking trays were properly stored and not stored in an office between boxes.These deficient practices could place residents at risk for food borne illness.The findings were:Observation during an initial tour of the kitchen on 6/23/25 at 9:20 a.m. revealed 3 packages of pulled pork were frozen, thawing out on a table near a sink. There was no water in the sink and the pork was still solid. The pork was sitting out at room temperature. Several bags of frozen cinnamon rolls and sweet potato fries were in gallon sized freezer bags that were not labeled and dated. Peas and some type of breaded meat were in sealed bags with no date or label. The peas appeared to have frost buildup. Cooking trays and muffin trays were stored in an office between open cardboard boxes. During an interview on 6/24/25 at 2:55 p.m., the Dietician said meat that was being thawed should not be sat out on a table to thaw . She said meat should be underwater with a continuous stream of water flowing to agitate the water. She said all foods in the freezer and refrigerator should be labeled and dated . She said cookware should be properly stored and not stored underneath boxes .During an interview on 6/25/25 at 1:50 p.m., the Dietary Manager said meat should be thawed under running cold water or thawed in the refrigerator. Leaving meat out to thaw on a kitchen prep table was not proper food handling. She stated it should have been under running water if it needed to be thawed quickly and was not thawed in the refrigerator. She said food should be labeled and dated. She said the labels of the foods found with no label or date may have fallen off. She said baking sheets should not be stored in the office. She said they should be stored in a proper location for sheet pans, 6 inches above the ground, and upside down. She said residents could be placed at risk of foodborne illness if food was not stored or handled properly .During an interview on 6/25/25 at 3:16 p.m., the Administrator said it was the responsibility of all staff which included the dietary manager to ensure safe food handling was being followed, foods were thawed properly, food was stored properly, and cooking pans were stored properly. He said the residents could be placed at risk for foodborne illness if eating foods were not handled properly.Record review of the facility's document, dated 12/01/2011, Food Preparation & Handling provided by the Dietary Manager revealed: The consultant dietitian will monitor the preparation and handling of food items to ensure that all food served by the facility is of good quality and safe for consumption according to the state and Federal Food Codes and Hazard Analysis and Critical Control Points guidelines. See Section 6 for Quality Assurance Monitor forms and schedule. The following guidelines should be followed Meat, poultry and fish is thawed in a refrigerator at 41 F. Foods may also be thawed using the following procedures: Completely submerged under cold potable running water with sufficient water velocity to agitate and float off loosened food particles into the overflow: For a period of time that does not allow thawed portions of ready-to-eat food to rise above 41 F; or For a period of time that does not allow thawed portions of a raw animal food requiring cooking to be above 41 F for more than 4 hours including the time the food is exposed to the running water and the time needed for preparation for cooking .Clean, sanitized surfaces, equipment and utensils are used.Record review of the facility's document, dated June 1, 2019, Food Storage provided by the Dietary Manager revealed: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and Hazard Analysis and Critical Control Points guidelines .To ensure freshness, store opened and bulk items in tightly covered containers. All containers must be labeled and dated .

Based on observation, interview and record review the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for palatable food. 1.The facility failed to provide meal services in a manner to ensure palatable food served was appetizing to residents.2.The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #60, #66, #58, and other anonymous complaints made during the resident council meeting who complained the food served did not taste good.These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.Findings include:During an interview on 6/23/25 at 10:03 a.m., Resident #60 said the food at the facility was not good. He said he preferred to not eat at the facility. He said he kept snacks in his room so he could get enough to eat since he did not eat much from the kitchen. During an interview on 6/23/25 at 10:15 a.m., Resident #66 said he liked living in the facility , but the food was terrible. He said the variety was fine, it was the taste. He said the flavor could be off. He said it was bland or sometimes overcooked as well as being cold by the time it got to him. During an interview on 6/23/25 at 10:22 a.m., Resident #58 said the food at the facility was just not good. He said the food didn't taste good, and it was bland. He said it came to him cold all the time and sometimes it had weird flavors. During an interview and observation with the Dietary Manager on 6/24/25 at 12:29 PM, a test tray with a regular diet was provided. The state survey team members and dietary manager sampled the test tray she said the sample tray that was tested did not meet her expectations with flavor or temperature. She said the food was bland and did not retain its heat coming out of the kitchen. She said it would help if she had plate warmers to keep the plates warm. She stated the cold plates acted like a heat sink, and it took the heat out of the food after it was plated. During the sampling the lemon butter chicken had a strong taste of lemon and little to no butter flavor. The lemon flavor overpowered all other flavors. The carrots lacked flavor and temperature. The garden rice and peas lacked temperature and flavor as well. The meal was served with vanilla ice-cream and there were no concerns with the ice-cream.During a confidential interview of 5 anonymous residents stated their food was always cold. Residents also stated the timings of lunch and dinners were late. During an interview on 6/25/25 at 3:08 p.m., the Director of Nurses said she ate a test tray randomly but did not eat out of the kitchen regularly. She said she felt the food she tested was fine to her. She said the residents who were not eating or eating less would be placed at risk for malnutrition and weight loss. During an interview on 6/25/25 at 3:16 p.m., the Administrator said he ate out of the kitchen previously, however he ate a carnivore diet and did not eat exactly what the residents ate. He said the residents who disliked the food served from their kitchen could be placed at risk for malnutrition and weight loss by not eating what was served. He said they switched food providers, and it was noticed a decline in appreciation from the residents for the new menus.Record review of the facility's Test Tray Evaluation policy, dated 08/22/2012, indicated: A test tray evaluation will be conducted by the consultant dietitian in accordance with the Quality Assurance Report Schedule or more often if concerns are noted with food temperatures, food quality or resident complaints.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 5 (Resident #53) residents reviewed. The facility failed to care plan Resident #53's JP, also called a Jackson Pratt drain (a surgical suction drain that gently draws fluid from a wound to help you recover after surgery). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. The findings included:Findings included:1. Record review of Resident #53's face sheet, dated 06/25/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Chronic kidney disease, also called chronic kidney failure (involves a gradual loss of kidney function), malignant neoplasm of kidney (a cancerous tumor in the kidney) diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and high blood pressure.Record review of Resident #53's admission MDS assessment, dated 04/21/25, indicated Resident #53 understood others and was understood by others. The MDS assessment indicated he had a BIMS score of 13, indicating he was cognitively intact. Resident #53 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS did not indicate the JP drain. Record review of Resident #53 's physician orders dated 04/19/24 indicated to empty the JP drain and document any drainage each shift and as needed. Record review of Resident #53 's physician orders dated 04/21/24 indicated to cleanse JP drain insertion site with normal saline and apply a gauze dressing; changed dressing every shift and as needed.Record review of Resident #53 's physician orders dated 04/21/24 indicated to monitor JP drain site for signs of infection: redness, swelling, warmth, purulent drainage (a thick, opaque, and often yellow or greenish fluid that indicates a wound infection), or fever. Notify the physician of any concerns.Record review of Resident#53's care plan, revised date of 05/15/25, did not indicate he had a JP drain. During an observation and interview on 06/23/25 at 11:24 a.m., Resident #53 was in his bed. Resident #53 had a JP drain on his right side. He said he had the JP drain since his admission.Record review of Resident #53 's care plan dated 06/24/25, after the surveyors' intervention indicated Resident #53 had a JP drain. The interventions were for staff to clean and treat the site as ordered and as needed .During an observation and interview on 06/24/25 at 2:57 p.m., the MDS coordinator looked at Resident #53's care plan and said she did not see the care plan for his JP drain. She said she was aware he had a JP drain and was not aware why it had not been care planned. The MDS coordinator said she and the IDT worked together to do the care plans. She said it was important to care plan the residents' care needed. She said she would care plan his JP drain. During an interview on 06/25/25 at 3:05 p.m., the DON said the MDS coordinator was responsible for completing the care plans. She said each IDT member was responsible for the acute care plans (IE: the treatment nurse did wounds, ADON did infections, and the DON did falls). The DON said she was unaware that Resident #53's JP drain was not care planned. She said the care plan painted a picture of the care the resident should receive. During an interview on 06/25/25 at 3:31 p.m., the Administrator said all disciplines should work together to complete a resident's care plan, but the MDS nurse was the overseer. He said Resident #53 was at risk of an infection if his JP drain was not cared for correctly. He said care plans were generated to provide each resident with the best care.Record review of the facility policy titled Care plans, Comprehensive Person-Centered, dated 12/2017, indicated Policy Statement: It is the policy of this home that staff must develop a comprehensive care plan to meet the needs of the resident. Plan: #6c. Individualize care to ensure the care plan is person-centered for the unique needs of the resident. 12. Resident Care Plan Documentation and Use of The Plan: C. The resident care plan must be always kept current.

Based on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care (Residents #1).The facility failed to ensure Resident #1's oxygen filter was in the back of the concentrator.This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease.Findings Included:Findings Included:Record review of Resident #1's face sheet dated 06/25/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses heart failure, personal history of COVID, altered mental status, anxiety, and high blood pressure. Record review of Resident #1's quarterly MDS dated [DATE] indicated she made herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 3 which indicated she had severely impaired cognition. The MDS also indicated she used oxygen while she was a resident. Record review of Resident #1's care plan dated 11/12/24 indicated she had and ADL selfcare deficit related to impaired cognition and impaired mobility with interventions for staff to provide supervision and assist resident to the bathroom when needed, provide supervision ad assist with transfers as needed, and provide moderate assistance with showers 3 times a week. The care plan also indicated Resident #1 had oxygen therapy with a goal for resident to have no signs and symptoms of poor oxygen absorption and interventions to provide oxygen per MD orders and monitor for signs and symptoms of respiratory distress. Record review of Resident #1's physician order report dated 05/25/2025-06/25/2025 indicated she had an order for:Oxygen: Change oxygen tubing, bubble humidification, and clean filters in use Q week. Once a day on Sunday night shift 22:00-06:00(10:00pm-6:00 am) with a start date 08/15/2022 and no end date. Record review of Resident #1's respiratory administration history dated 06/01/2025-06/25/2025 indicated LVN K signed off as completing the order:Oxygen: Change oxygen tubing, bubble humidification, and clean filters in use Q week. Once a day on Sunday night shift 22:00-06:00(10:00pm-6:00 am) on 06/22/25. During an observation and interview on 06/23/25 at 11:25 AM Resident #1 was sitting in her room and had an oxygen concentrator beside her bed that did not have a filter in it. Resident #1 said she used her oxygen every night. During an observation on 06/24/25 at 08:40 AM Resident #1's oxygen concentrator in her room had no filter. During an observation on 06/25/25 at 08:15 AM Resident #1's oxygen concentrator in her room had no filter. During an observation and interview on 06/25/25 at 03:39 PM Resident #1's oxygen concentrator in her room had no filter and LVN L said the oxygen filters and the tubing were changed out by night shift nurse on Sundays. LVN L said there should have been a filter in the concentrator. She said the failure placed Resident #1 at risk infection because the filter was used to block dirt, bacteria, and trash from going into her nasal cavity. During an interview on 06/25/25 at 03:53 PM the DON said her expectation was for the oxygen concentrator filter to be in place and clean. The DON said the night shift nurses were responsible for changing the tubing and cleaning the filters on Sundays. The DON said the failure placed a risk is for the oxygen concentrator not working properly and placed a risk for infection. During an interview on 06/25/25 at 04:03 PM the Administrator said he expected the staff to be properly trained and for nurses to inspect and change the oxygen concentrator tubing and filters He said the floor nurses should ensure the filters were replaced correctly and working properly. The Administrator said the DON as well as the floor nurses were responsible for ensuring the oxygen concentrators were clean and operating properly. The Administrator said the failure placed Resident #1 at risk of contamination. During an attempted call on 06/25/25 at 04:19 PM LVN K (the night nurse who signed the order for cleaning the oxygen filter as completed) did not answer.Record review of the facility policy Respiratory Therapy Equipment dated 12/2017 indicated:POLICYIt is the policy of this home that residents on respiratory therapy will have appropriate treatment. Only trained licensed staff will administer respiratory therapy. Respiratory equipment used to provide therapy will be maintained appropriately.PROCEDUREOxygen Administration1. Obtain equipment (i.e., oxygen tubing, reservoir, and distilled water) .9. Wash filters from oxygen concentrators every 7 days in soapy water. Rinse and squeeze dry .

Based on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident #15) reviewed for trauma-informed care.The facility did not ensure Resident #15's care plan had specific triggers for his diagnosis of PTSD, also known as post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Resident #15 had a history of trauma.This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.Findings included:Record review of Resident #15's face sheet, dated 06/25/25, indicated Resident #15 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses which Post-traumatic stress disorder also known as PTSD (a mental health condition that can develop after a person has experienced or witnessed a traumatic event), Parkinson (a progressive neurological disorder that primarily affects movement, but also has non-motor symptoms), and depression(sadness).Record review of Resident #15's quarterly MDS, dated [DATE], indicated Resident #15 usually understood others and made himself understood. Resident #15 had a BIMS score of 09, which indicated his cognition was moderately impaired. The MDS assessment indicated Resident #15 had a diagnosis of post-traumatic stress disorder. Record review of Resident #15's trauma assessment dated [DATE] indicated he had a history of trauma, PTSD, and physical assault.Record review of Resident #15's comprehensive care plan, dated 01/27/25, indicated Resident #15 had a diagnosis of PTSD, at risk for anxiety, hallucinations, irritability, difficulty sleeping, lack of interest in activities, and easily startled/frightened. The interventions were to administer medications per physician orders, provide extra time and address resident slowlyand calmly to attempt to decrease risk of startling resident.During an interview on 06/25/25 at 9:42 a.m., CNA N said she was Resident #15's aide and was not aware he had a diagnosis of PTSD or what his triggers were.During an interview on 06/25/25 at 9:48 a.m., LVN O said she was aware Resident #15 had PTSD but did not know his specific triggers. She said it was important to know if someone had trauma, triggers, and how to manage their triggers. She said they could have triggers from the war, military, or anything. She said staff should be aware of any triggers the resident had to be able to care for the resident.During an interview on 06/25/25 at 9:50 a.m., the Social Worker provided Resident #15's completed trauma assessment. She verified he had PTSD on his assessment. She said his triggers were loud noises and water. The Social Worker looked at Resident #15's care plan and did not see where his specific triggers were care planned. The Social Worker said PTSD/trauma and the triggers should be placed in the care plan by either her or the MDS Coordinator. The Social Worker said it was important to have Resident #15's triggers on the care plan so that staff were aware of his triggers.During an interview on 06/25/25 at 9:52 a.m., the MDS coordinator said the SW usually did the PTSD care plan. She said the care plan was implemented so that staff would know what triggers to look for. She looked at Resident #15's care plan and saw where he could be startled but did not specifically say loud noises or water. She said she would add to his care plan so staff would be aware.During an interview on 06/25/25 at 10:02 a.m., Resident #15 was lying in his bed. He said he had been in the Vietnam War, and his triggers were loud noises, war pictures, and water at times. He said it rained a lot during the war. During an interview on 06/25/25 10:52 a.m., the DON said she updated his care plan to reflect exactly what the trauma assessment said and did an in-service so that staff were aware of Resident #15's triggers. The DON did not provide the surveyor with the in-service given on Resident #15 triggers.During an interview on 06/25/25 02:53 p.m., the DON said they did not have a policy on trauma or informed care. During an interview on 06/25/25 at 3:05 p.m., the DON said the Social Worker was responsible for the trauma-informed assessments. She said the MDS coordinator was responsible for the comprehensive care plans. She said she expected the triggers to be on the care plan so that staff were aware of the triggers. She said if the triggers were not care planned, staff would not know the trigger and how to care for the resident.During an interview on 06/25/25 at 3:31 p.m., the Administrator said the care plan should reflect the assessment. He said the assessment should be done by the SW, and she should make sure the care plan matches. He said he should follow up to make sure the care plan and audits match. He said the trauma care plan should be specific to the resident's triggers, and if not, staff will not know what not to do or what could cause a trigger.

BASED on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 21 residents reviewed for medications. (Resident #30)The facility failed to ensure Resident #30's Remeron (mirtazapine) (antidepressant medication) was decreased on 04/10/25 when the medical director signed the pharmacy recommendation and agreed to decrease the Remeron (mirtazapine) from 22.5mg to 15mg every night. This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication.Findings include:Record review of Resident #30's face sheet dated 06/25/25 indicated he was an [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses Alzheimer's disease, diabetes mellitus, heart disease, depression, and anxiety. Record review of Resident #30's significant change MDS dated [DATE] indicated he usually makes himself understood and usually understood others. The MDS also indicated he had a BIMS score of 5 which indicated severely impaired cognition. The MDS also indicated Resident #30 was dependent on staff for transfers, bed mobility, bathing and eating. Record review of Resident #30's care plan dated 04/17/25 indicated he had potential for side effects related to psychotropic medication use (antipsychotic, antidepressant) with interventions in place for the pharmacy consultant to review medications periodically for possible reduction, and for the staff to administer medications for conditions as ordered.Record review of Resident #30's physician order report dated 05/25/25-06/25/25 indicated he had and order for:1.Remeron (mirtazapine) 15mg tablet oral to give with 7.5mg tablet to=22.5mg once a day at 18:00-22:00(6:00 PM-6:00 AM) with a start date of 06/11/24 and no end date.2.Mirtazapine 7.5mg tablet oral to give with 15mg tablet to=22.5mg once a day at 18:00-22:00(6:00 PM-6:00 AM) with a start date of 06/11/24 and no end date.Record review of Resident #30's note to attending physician/prescriber dated 03/30/25 indicated Resident #30 had been taking the antidepressant REMERON 22.5MG QD since 5/2024. The note to the attending physician/prescriber was signed in agreement by the MD with a rationale to decrease the Remeron (mirtazapine) from 22.5mg to 15mg every night. Record review of Resident #30's medication administration record dated 06/01/25-07/01/25 indicated Resident #30 continued to receive the Remeron (mirtazapine) 22.5mg dose every night until 06/25/25 after surveyor intervention. During an interview on 06/25/25 at 03:30 PM LVN M said she was not taking care of Resident #30 in April 2025, she was working in the locked unit. She said that by reading the order noted by the physician on the note to attending physician/prescriber dated 03/30/25 she would have changed the order for the Remeron (mirtazapine). During an interview on 06/25/25 at 03:51 PM the DON said she oversaw the process for the pharmacy recommendations. She said the charge nurses gets the signed orders and the nurse would be responsible for changing the orders and provide the signed note to the attending physician/prescriber to the DON for follow up to ensure the orders were completed. She said she just missed Resident #30's note to the attending physician/prescriber. The DON said the charge nurse possibly did not give the note to her after completing it to verify and ensure order was carried out. The DON gave Resident #30's signed note to attending physician/prescriber dated 03/30/25 to the ADON for the orders to be updated in the computer and told the ADON to notify the MD. The DON said the failure placed a risk for Resident #30 having improper doses of medication and unnecessary medications. During an interview on 06/25/25 at 04:07 PM the Administrator said his expectation was for the nursing staff to ensure gradual dose reductions from the pharmacy and nursing orders were followed. The Administrator said the failure placed a risk for Resident #30 but he was not exactly sure about what risk, but he said he expected the medication to be decreased as ordered. Record review of the facility policy Behavior Management-Psychoactive Medication-Antipsychotic Drug Therapy dated 12/2017 indicated:POLICYIt is the policy of this home to use antipsychotic medications per CMS guidelines and to perform dose reductions and monitoring as required by regulation, to promote the highest level of resident care and safety.DEFINITIONS1. A gradual dose reduction is a tapering of the resident's daily dose to determine if the resident's symptoms can be controlled by a lower dose or to determine if the dose can be eliminated altogether .

Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities, which involved 2 of 6 residents (Resident #66 and Resident #1) reviewed for medication administration.The facility failed to ensure LVN P administered Resident #66's medication of Omeprazole (a medication used to treat conditions involving excessive stomach acid production) correctly on 06-24-25.The facility failed to ensure LVN Q administered Resident #1's medication of fluticasone (a corticosteroid used to treat a variety of inflammatory conditions, primarily those related to allergies and asthma) correctly on 06-24-25.These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.Findings included:1.Record review of a face sheet dated 06/25/225 indicated Resident #66 was an [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included Coronary artery disease also known as CAD (a narrowing or blockage of your coronary arteries, which supply oxygen-rich blood to your heart), dementia (deterioration of memory, language, and other thinking abilities with behaviors), GERD or gastroesophageal reflux disease (a digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and discomfort). and high blood pressure. Record review of the admission MDS assessment dated [DATE] indicated Resident #66 understood others and was understood by others. The MDS assessment indicated Resident #66's BIMS score was a 12, which indicated his cognition was moderately impaired. Record review of Resident #66's Order Summary Report dated 04/21/25 indicated the following order: Omeprazole 20 mg tablet, delayed release; give: 2 tablets by mouth twice a day.Record review of Resident #66's June 2025 MAR indicated his Omeprazole 40mg was given on 06/24/25 by LVN P.Record review of Resident #66's care plan, last reviewed 05/21/25, indicated he had a diagnosis of GERD. The interventions were for staff to administer medications as ordered and monitor/document side effects and effectiveness.During an observation of medication administration on 06/24/25 starting at 8:24 a.m., LVN P administered one Omeprazole 20 mg but did not administer two 20mg tablets to equal 40 mg for Resident #66.During an attempted interview on 06/25/25 at 10:18 AM, LVN P did not answer the phone; a message was left.2. Record review of a face sheet dated 06/25/225 indicated Resident #1 was an [AGE] year-old female re-admitted to the facility on [DATE] with diagnoses which included heart failure also known as congestive heart failure( occurs when the heart muscle can't pump enough blood to meet the body's needs), dementia (deterioration of memory, language, and other thinking abilities with behaviors), GERD or gastroesophageal reflux disease (a digestive disorder where stomach acid frequently flows back into the esophagus, causing irritation and discomfort). and high blood pressure. Record review of the quarterly MDS assessment dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS assessment indicated Resident #1's BIMS score was 03, which indicated her cognition was severely impaired. Record review of Resident #1's Order Summary Report dated 04/21/25 indicated the following order:Flonase Allergy Relief (fluticasone) spray, suspension; 50 mcg; give 2 sprays; each nasal twice a day.During an observation of medication administration on 06/24/25, starting at 8:49 a.m., LVN Q administered one spray of fluticasone 50 mcg but did not administer two 50 mcg sprays to Resident #1.During an interview on 06/25/25 at 2:04 p.m., LVN Q said she should have given Resident #1 2 sprays to each nostril. She said she thought she gave 2 sprays, but looking back, she did not. She said she should have followed the physician's order. She said she was not aware how the resident would be effected if she did not receive 2 nasal sprays.During an interview on 06/25/25 at 3:05 p.m., the DON said she expected nurses to follow orders and give medication as ordered. She said she, the ADON, and the pharmacist monitored the nurses to ensure they were administering medications correctly by conducting periodic medication checkoffs. The DON said if medications were not administered per the doctors' orders, the problem or reason the medication was intended for was not going to be resolved. She said they did not have a policy on physicians' orders.During an interview on 06/25/25 at 3:31 p.m., the Administrator said he expected medications to be administered per the doctors' orders and for there not to be any mistakes. The Administrator said the DON and ADON were responsible for monitoring to ensure medication errors did not occur. The Administrator said medication errors could affect residents depending on the medication and why ordered.Record review of the facility policy titled, Medication Administrator, dated 12/2017, indicated, Policy: It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations.

Based on observation, interview, and record review, the facility failed store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 21 residents reviewed in sample (Resident #1).The facility failed to ensure Resident #1 did not have hibliclens antiseptic skin cleanser (skin cleanser usually used in surgery to prevent skin infections) in her bathroom on the shelf.These failures could place residents at risk of injury.Record review of Resident #1's face sheet dated 06/25/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses heart failure, personal history of COVID, altered mental status, anxiety, and high blood pressure. Record review of Resident #1's quarterly MDS dated [DATE] indicated she made herself understood and was able to understand others. The MDS also indicated she had a BIMS score of 3 which indicated she had severely impaired cognition. The MDS also indicated she used oxygen while she was a resident. Record review of Resident #1's care plan dated 11/12/24 indicated she had and ADL selfcare deficit related to impaired cognition and impaired mobility with interventions for staff to provide supervision and assist resident to the bathroom when needed, provide supervision ad assist with transfers as needed, and provide moderate assistance with showers 3 times a week. During an observation on 06/24/25 at 08:40 AM Resident #1 had hibliclens antiseptic cleanser in her bathroom on the shelf. During an observation on 06/25/25 at 08:15 AM Resident #1 had hibliclens antiseptic cleanser in her bathroom on the shelf. During an observation and interview on 06/25/25 at 03:42 PM Resident #1 had hibliclens antiseptic cleanser in her bathroom on the shelf and LVN L said the hibliclens antiseptic cleanser should not have been in Resident #1's bathroom on the shelf. LVN L threw the hibliclens antiseptic cleanser in the trash and said the failure placed a risk for Resident #1 or any resident drinking the hibliclens antiseptic cleanser. LVN L said the hibliclens antiseptic cleanser should be stored in medication rooms or the medication carts.During an interview on 06/25/25 at 03:55 PM the DON said Resident #1's family had to have brought the hi9bliclens antiseptic cleanser into the facility because they did not have it in the facility. The DON said all staffed nurses, CNAs, and staff who completed rounds to check rooms on that hall were responsible for ensuring medications were not left out in the room. The DON said the failure placed a risk of causing harm to Resident #1 or other residents from ingesting because the hibliclens antiseptic cleanser is something the residents should not have. During an interview on 06/25/25 at 04:05 PM the Administrator said Resident #1 should not have anything like hibliclens antiseptic cleanser in the room. He said any type of medications should be store properly in the medication cart or the medication room. The Administrator said the failure placed a risk for Resident #1 or other residents hurting themselves by ingesting the hibliclens. Record review of the facility policy Med Storage-in the Home dated 12/2017 indicated:POLICYIt is the policy of this home that medications will be stored appropriately as to be secure from tampering, exposure or misuse.PROCEDURE1. The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable. Medications are kept and stored in these containers. Only a pharmacist does transfer of medications from one container to another.2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications (i.e., medication aides, etc.) are allowed access to medications. Medication rooms, carts, and medications supplies are locked or attended by persons with authorized access .

Based on interview and record review the facility failed to conduct and document a facility wide assessment to determine what resources were necessary to care for it's residents competently during both day-to-day operation, including nights and weekend, and emergencies for 1 of 1 facility assessment reviewed for administration and 1 resident who received dialysis (Resident #53).The facility failed to ensure the assessment accurately reflected dialysis patients.This deficient practice could place residents at risk for inadequate care or treatmentsThe findings include:Record review of the Facility assessment dated [DATE] (date of assessments or update) read in part: . Special Treatments and Conditions . dialysis. Number/Average or Range of Residents . 0 . Record review of Resident #53's face sheet, dated 06/25/25, indicated a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #53 had diagnoses which included Chronic kidney disease, also called chronic kidney failure (involves a gradual loss of kidney function), malignant neoplasm of kidney (a cancerous tumor in the kidney), diabetes (a disease that occurs when your blood glucose, also called blood sugar, is too high), and high blood pressure.Record review of Resident #53's admission MDS assessment, dated 04/21/25, indicated Resident #53 understood others and was understood by others. The Resident #53 had a BIMS score of 13, which indicated he was cognitively intact. Resident #53 required assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. Resident #53 received dialysis. Record review of Resident #53's care plan, dated 04/21/25, indicated he was scheduled for dialysis on Tuesday, Thursday, and Saturdays. Record review of Resident #53's orders indicated the resident's dialysis order was dated 04/21/25.During an observation and interview on 06/24/25 at 3:30 p.m., the Administrator said he had 1 resident, Resident #53, who received dialysis. He looked at the facility assessment and said Resident #53 should have been on the facility assessment. He said he reviewed the facility assessment on 06/19/25 but did not realize Resident #53 had not been added; he said it was an oversight. He said he just missed the dialysis being documented and it was important to have the facility assessment accurate because it reflected the care they provided to the residents in the facility.During an interview on 07/01/25 at 01:32 PM, the DON said the facility did not have a policy for facility assessment.

Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised which resulted in Resident #1 leaving the facility on 08/12/24, walking approximately 0.5 miles , and crossing a busy 2 lane road. The facility failed to ensure the ADON put measures in place to keep Resident #1 from leaving the facility when she said she saw Resident #1 climb the fence. The facility failed to monitor and put measures in place to keep Resident #1, who was high risk for elopement, from eloping after voicing wanting to go home. The noncompliance was identified as PNC. The IJ began on 08/12/24 and ended on 08/14/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of potential accidents, injuries, harm, or death. Findings included: Record review of Resident #1's face sheet dated 03/04/25, indicated a [AGE] year-old male who admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (memory loss) with behaviors, anxiety (mental health condition characterized by excessive worry, fear, and nervousness), depression (mental health condition characterized by persistent feeling of sadness, loss of interest, and low energy that can significantly interfere with daily life), and hypertension (high blood pressure). Record review of Resident #1's admission MDS assessment dated [DATE], indicated Resident #1 was usually understood and sometimes understood others. Resident #1 had a BIMS score of 4, which indicated his cognition was severely impaired. Resident #1 had delusions and received hospice care. The MDS assessment indicated Resident #1 did not wander. Resident #1 required setup or clean up assistance with eating, oral hygiene, toileting, and personal hygiene. Record review of Resident #1's comprehensive care plan dated 08/12/24 and last revised on 08/14/24 indicated Resident #1 was at risk for elopement as evidenced by repetitive statements of going home. The care plan interventions indicated staff to orient and redirect resident as needed, attempt to find the source of behaviors, divert resident's attention, and refocus attention elsewhere, elopement assessment performed quarterly, with significant change, and as needed, monitor and record behaviors, when it occurred and notify physician and family of any further concerns. Record review of Resident #1's physician order reported dated 08/01/24-08/31/24 indicated Resident #1 had the following orders: o Depakote 125mg give one tablet by mouth once a day for dementia with behavioral disturbances and a start date of 06/11/24. o Donepezil 10mg give one tablet by mouth once a day for dementia with behavioral disturbances and a start date of 06/11/24. o Quetiapine 25mg give one tablet by mouth once a day for dementia with behavioral disturbances and a start date of 06/11/24. o Lorazepam 1mg give one tablet by mouth twice a day for anxiety with a start date of 06/13/24. o Paroxetine 20mg give one tablet by mouth once a day for depression with a start date of 07/12/24. o Vistaril 25mg give 2 tablets by mouth every 8 hours as needed for anxiety with a start date of 08/12/24. o Do not send to ER without calling [hospice company] first with a start date of 06/06/24. o May transfer to [behavioral health facility] for evaluation with a start date of 08/14/24. Record review of Resident #1's elopement/wandering assessment dated [DATE], completed by RN F, indicated Resident #1 exhibited 1 or more high risk factors to wander, which indicated he was classified as a high risk to wander. The elopement/wandering assessment for Resident #1 indicated he had the following high-risk factors to wander: a history of wandering prior to admission to the facility, exhibited wandering behavior, resident followed others around, verbalized the need and or desire to go home or to another location and had the ability to act on that verbalization. The assessment indicated the intervention was the secured unit. The assessment also indicated Resident #1 did not know the location of his current residence. Record review of Resident #1's progress note dated 08/07/24 at 11:43 PM signed by RN F indicated .Resident awake and very agitated. Refuses to go to bed and keeps saying that he drove himself here in his mother's car, and that she will need it to drive to work in the morning. States that we are holding him against his will and has torn down all of the notes we had hanging up to remind him of why he was here. He says that his Dr did not put him here, and that he doesn't have a wife, He went to door at NS and shook it very hard, He also said he is going to sue this company, and burn it down, He says he does not mind going to jail, because that would be better than staying here. Sitting in recliner at NS at this time. Trying to redirect him we offered to call his wife for him, but he refused saying that we were lying to him about him having a wife. When I suggested we just call her and see if she answers and was adamant that he did not want me to call anyone. Record review of Resident #1's progress note dated 08/08/24 at 12:33 AM and signed by RN F indicated . Resident continues to escalate with his behaviors. He is shoving on doors and hitting them with his hand. DON notified and she asked if he had had his PRNs. I said yes and she said called [MD]. [MD] said send him to ER. EMS arrived and we talked him into getting on the stretcher by telling him he was going to get outside of these doors. EMS is gone with him. Record review of Resident #1's progress note dated 08/08/24 at 4:30 AM and signed by RN F indicated . Resident returned from ER. Alert and ambulatory. Pacing and carrying his personal possessions with him. He is shadowing everyone that starts toward an exit door, and muttering something about he has to get home. We are monitoring him closely. Notified [hospice company] that resident was back in the building. Record review of Resident #1's progress note dated 08/08/24 at 6:17 AM and signed by RN G indicated . Resident exhibits increase agitation, approaches nurses station asking this write to leave facility. Resident noted to have personal belongings packed within personal reach. Writer attempts to redirect to other activities, currently unsuccessful at this time. Resident refusing vital sign checks and medication administration at this time. Will attempt to redirect and provide care as resident tolerates. Record review of Resident #1's progress note dated 08/08/24 at 08:00 AM and signed by RN G indicated . Resident continues to push on exit doors, making verbal demands to leave secured unit. Writer attempts to redirect resident to other activities, currently unsuccessful at this time. Resident continues to refuse foods, fluids, vital sign checks, and scheduled medication at this time. Will continue to attempt to redirect and offer care as resident tolerates. Record review of Resident #1's elopement/wandering assessment dated [DATE], completed by RN G, indicated Resident #1 exhibited 1 or more high risk factors to wander, which indicated he was classified as a high risk to wander. The elopement/wandering assessment for Resident #1 indicated he had the following high risk factors to wander: *a history of wandering prior to admission to the facility, *exhibited wandering behavior, *resident had on (1) or more occasions attempted to exit or has exited the facility in an effort to wander away, whether intentionally or due to confusion, *resident followed others around, *verbalized the need and or desire to go home or to another location and had the ability to act on that verbalization. The assessment indicated the potential interventions were secured unit, review medications, recreational activities, personalization of room with familiar objects and photographs, staff aware of resident's elopement risk, and staff aware of resident's wander risk. The assessment indicated Resident #1 did not recognize stop lights and signs, and he did not know precautions when crossing streets or the location of his current residence and was not able to recognize physical needs. Record review of Resident #1's progress note dated 08/12/24 at 4:28 PM and signed by the DON indicated . Family and CNA reported to writer that resident is making threats to self-harm. Stating 'if I have to stay here, I am going to kill myself'. When staff attempted to redirect resident became agitated and threatened to kill staff member. Staff report Resident has been increasingly agitated, and hospice had been notified for med management. All attempts to redirection unsuccessful at this time. MD, family aware. Suggestion to send to behavioral health for safety needs at this time. [family member] at bedside and aware. Resident on 1:1 care at this time. Record review of Resident #1's progress note dated 08/12/24 at 6:42 PM and signed by LVN B indicated . at 15:00 (3:00 PM) resident went outside for scheduled break with CNA. At the end of the scheduled break at approximately 15:15 (3:15 PM) resident refused to come back inside. Resident then made threats to the CNA and continued to refuse to come inside. SN approached resident and asked him to come incident and resident then made references to self-harm. SN then contacted Hospice Services about resident escalating behavior. SN then contacted resident's RP who stated she would come up to the facility to talk with resident. RP arrived at approximately 16:45 (4:45 PM) and was able to talk to resident into coming back inside. Hospice nurse arrived shortly after and contacted MD and received an order for hydroxyzine 50mg PO Q8 hrs. PRN. Medication was administered at approximately 17:30 (5:30 PM). At approximately 18:00 (6:00 PM) resident is resting in bed with eyes closed, resident now has a one-on-one nurse to monitor for the remainder of this shift. SN will follow up. Record review of Resident #1's hospice visit note dated 08/12/24 at 11:54 AM completed by Hospice RN A indicated . Pt was sitting outside in the courtyard. He had just finished his lunch. He was pleasant. No complaints voiced. The nurse stated that earlier the pt refused to come inside and he had to work with him a long time to get him to come in. The [Resident #1's family member] stated when I spoke to her that he prefers to be outside. Pt was not anxious or agitated. Record review of Resident #1's elopement/wandering assessment with an observation date of 08/12/24 completed by the DON on 08/13/24, indicated Resident #1 exhibited 1 or more high risk factors to wander, which indicated he was classified as a high risk to wander. The elopement/wandering assessment for Resident #1 indicated he had the following high-risk factors to wander: *a history of wandering prior to admission to the facility, *exhibited wandering behavior, *resident followed others around, *verbalized the need and or desire to go home or to another location and had the ability to act on that verbalization. The assessment was answered No to the question asking if Resident #1 had on (1) or more occasions attempted to exit or had exited the facility in an effort to wander away, whether intentionally or due to confusion. The assessment indicated the potential interventions were secured unit, review medications, recreational activities, music, personalization of room with familiar objects and photographs, staff aware of resident's elopement risk, and staff aware of resident's wander risk. The assessment indicated Resident #1 did not know precautions when crossing streets, and he did not know the location of his current residence. Record review of Resident #1's hospice client coordination note dated 08/13/24, indicated on 8/12/24 the following occurred: 15:03 (3:03 PM) received a call from [hospice staff] at the office that [LVN B] had called and said that [Resident #1] behavior was escalating. He is out in the courtyard and had removed his shirt, swearing and refusing to come inside. He asked the aide to kill him. 1514 (3:14 PM) I called [Resident #1's family member] and updated her and I was headed to the facility. [Resident #1's family member] said her and [another family member] would be there ASAP. 1545 (3:45 PM) I was driving south on [name] st on the way to the facility when I spotted [Resident #1] walking north. I turned around to keep a visual on him as I called [Resident #1's family member]. She was walking looking for him. [Resident #1's other family member] pulled up and got him in the car. 1600 (4:00 PM) updated [MD]. 1600 (4:00 PM) Pt is sitting in the lobby at the facility with [his family member]. He is always calm [with family member]. After meeting with staff and the family it was decided that the best action for the pt is for him to go to a behavioral unit bc he is a danger to himself. He has been discussing wanting someone to kill him. 1700 (5:00 PM) A bed will be available in the am. The facility placed with the pt 1:1 spoke with [MD]. New order received for hydroxyzine 50mg q 8 hrs PRN. Order written. Educated staff and family on new meds, actions and side effects. Staff is aware to call the emergency number with any questions changes or concerns. Record review of Resident #1's hospice discharge visit note dated 08/14/24 and signed by Hospice RN A, indicated under discharge summary . pt was admitted to hospice after a decline in physical status. admitted to [facility] memory care bc he was no longer safe at home. Pt did not do well at the facility. He eventually got out of the facility. Pt was sent to [behavioral unit]. Record review of the facility incident and accident reports from July 2024-February 2025 did not indicate any elopement incidents. During an interview on 03/03/25 at 09:53 AM, Resident #1's family member said the day of the incident (08/12/24), they received a call from the facility regarding Resident #1's behaviors. Resident #1's family member said they told the nurse they would return to the facility. Resident #1's family member said they called the hospice nurse to meet them there to see what could be done regarding Resident # 1's behaviors. Resident #1's family member said when they arrived at the facility, Resident #1 was not there. Resident #1's family member said the facility staff were unable to locate Resident #1. Resident #1's family member said no one at the facility knew Resident #1 was missing or how long he had been missing. Resident #1's family member said Resident #1 had escaped out the fence and the hospice nurse (unsure of name) found him 3 miles down the road past the middle school. Resident #1's family member said the hospice nurse was the one that followed him until they got there to get him in the car. Resident #1's family member said she wrote the facility a statement when they returned Resident #1 to the facility. Resident #1's family member said Resident #1 was being unmonitored by the facility staff. During an interview on 03/03/25 at 10:47 AM, the Hospice Patient Care Manager said there had been an incident where Resident #1 climbed the fence and left the facility. The Hospice Patient Care Manager said Hospice RN A was on her way to the facility, Hospice RN A happened to turn to look at a person who was walking by, and realized it was Resident #1, so she turned around and followed him. During an interview on 03/03/25 at 11:37 AM, Hospice RN A said the day of the incident (08/12/24) she had been at the facility earlier that day and Resident #1 had been calm. She said she knew what Resident #1 was wearing that day. Hospice RN A said around 4:00 pm, she received a call from his nurse that Resident #1 was agitated. Hospice RN A said they had instructed the facility staff to call them with any behaviors because Resident #1's family member had the ability to calm him down. Hospice RN A said she told the facility she was on her way and then called Resident #1's family member. Hospice RN A said she had been on [name] street, a street close to the local pharmacy, when a longhorns shirt caught her eye. She said she turned to look and realized it was Resident #1. She said, There goes my patient. Hospice RN A said she turned around and called Resident #1's family member. Hospice RN A said Resident #1's family member was screaming we can't find him. She said she told her she knew where Resident #1 was, and they came and got him. Hospice RN A said Resident #1 was placed on one on one when he returned to the facility, and he was sent to a behavioral hospital on 08/14/24. During an observation on 03/03/25 at 12:25 PM, the middle school was observed to be located north of the facility, approximately 0.5 miles crossing a busy 2 lane road. During an interview on 03/03/25 12:43 PM, LVN B said he was no longer employed at the facility but had worked the secure unit on the 2:00 PM - 10:00 PM shift. LVN B said Resident #1 had not eloped on 08/12/24. LVN B said he had eyes on Resident #1 the whole time. LVN B said Resident #1 was the resident that did not want to come back inside. LVN B said Resident #1 was hard to handle, but he had not run away that he was aware of. He said Resident #1 was placed on one-on-one monitoring due to his behaviors. LVN B said he was unsure of who sat with him, since management did that. He said he notified hospice regarding Resident #1's behaviors. He said if he had a resident who eloped he would notify the supervisor and follow the facility's protocol, call the MD, call the family and call 911, if the resident was out of sight. During an interview on 03/03/25 at 2:19 PM, CNA C said she had been working in the secure unit on 08/12/24. CNA C said she remembered Resident #1's family member visited with him the morning of 08/12/24. CNA C said Resident #1 wanted to go home with his family member, and he wanted to go out of the facility. CNA C said they took Resident #1 out to smoke in the secured smoking area by the unit around 3 PM. CNA C said when Resident #1 went outside to smoke they could not get him back inside the facility, and he refused to go back into the facility. CNA C said she kept an eye on him and at one point he hid behind a tree. She said all of a sudden, she could not see him. CNA C said they found him close unsure of location. She said the Maintenance Supervisor was out looking for him, and she was unsure of who else. CNA C said she was keeping an eye on Resident #1 by peeking through the door occasionally after providing care to other residents. CNA C said she reported to the charge nurse Resident #1 was no longer outside and he alerted everyone else. CNA C said the charge nurse was also keeping an eye on him. CNA C said they thought fresh air would help him with his behaviors. She said she never imagined Resident #1 would climb over the fence. CNA C said if she had a resident that voiced wanting to leave or trying to elope, she would notify the DON and charge nurse and not take the resident outside. During an interview on 03/03/25 at 2:29 PM, the SW on 8/12/24, she knew that a staff member followed him (unsure of who) down the street. She said she did not know how far he went or who brought him back. The SW said Resident #1 was sent to a behavioral hospital first, and then to another facility. During an interview on 03/03/25 at 2:30 PM, the DON said Resident #1 did not elope because he was followed by the ADON. The DON said Resident #1 was walking down the road by the school. The DON said when Resident #1 was in the facility's parking lot he told the ADON he was not getting in the car. The DON said the ADON followed him until the family got there. The DON said family and hospice was called and they were on the way to the facility. The DON said they provided staff with elopement in-services and completed elopement assessments for all residents in the secure unit. The DON said they in-serviced staff because had the ADON not been out there to see him, it would have been an elopement and there could have been a worse outcome. During an interview on 03/03/25 at 2:31 PM, the Administrator said the day of the incident the ADON was with Resident #1, and he did not want to get in her car. She said she did not remember how far he had gone but believed it was by the mobile home park in front of the facility. The Administrator said she was unsure if Resident #1 had voiced he wanted to leave. The Administrator said she expected when a resident eloped or was trying to elope that they get them back in the facility safely. She said they had educated staff if a resident was not found a code pink (missing resident) should be called, the police should be notified, and everyone for all hands-on deck for a successful trip back home. During an interview on 03/03/25 at 2:36 PM, the ADON said Resident #1 did leave the facility. The ADON said she was outside in her car on 08/12/24 and saw Resident #1 climb the fence. She said she had tried to get him in the car, but he refused. She said she followed him at a safe distance in her car. The ADON said Resident #1 walked straight and crossed the road toward the school. The ADON said the family met him where we were and brought him back to the facility. The ADON said she had called the DON. The ADON said they had called hospice and family to let them know Resident #1 had been trying to beat up the staff, and Resident #1's family was headed to the facility. The ADON said she was unaware of who all knew but the DON knew I was following him. The ADON said if Resident #1 had actually eloped, the DON and Administrator would have notified all channels, family, and MD. The ADON said it was best to keep eyes on him. During an interview on 03/03/25 at 2:56 PM, Hospice RN A said the SW found him right after she did, and the SW had made eye contact with her. She said she did not recall if the ADON was at the site where Resident #1 had been picked up. During an interview on 03/03/25 at 3:03 PM, Resident #1's family member said there was no facility staff at the site where Resident #1 was found that they were aware of. Resident #1's family member said the hospice nurse told them she was on [name] street. Resident #1's family member told the hospice nurse he was not going to get in her car with her because he did not know her, and they did not want the hospice nurse to set him off. Resident #1's family member said she walked to him and the other family member drove. Resident #1's family member said the facility staff had no clue he was missing. During an interview on 03/04/25 at 09:05 AM, the Regional Director of Operations said he had asked the ADON if she had provided a written statement to the surveyor regarding the incident that occurred on 08/12/24. The Regional Director of Operations said the ADON told him they did not provide a written statement to the surveyor. The Regional Director of Operations said he had asked the ADON if she had her phone with her that day and she said she did and that she had called the DON. He said LVN B was also keeping an eye on Resident #1 by looking out through the door of the secure unit. During an interview on 03/04/25 at 10:06 AM with the Regional Director of Operations, Regional Nurse Consultant, the Administrator, the DON, and ADON, the DON said she had spoken to [LVN B] that morning and he had told her it was not considered an elopement if it was witnessed. State Surveyor questioned how come the incident was not documented anywhere in Resident #1's electronic medical record, and the DON said she had educated [LVN B] on documentation and he had walked off when they were trying to educate him. The DON said LVN B said, he was not going to work like this and left. State surveyor questioned how come no other staff member went to assist the ADON, the DON said she went out the front door and did not see him, and she called hospice and the family. The DON said the family did not answer. The DON said they did not go because Resident #1 was being belligerent, to not make the situation worse and the ADON was already in her car and was following him. The ADON said she did not see Resident #1 jump the fence she saw him outside the fence. The DON said the family had not arrived at the facility prior to the incident and the family was seen when they were bringing him back to the facility. The DON said the family had told the Administrator and herself that they had seen the ADON in her car. The DON said when she became aware of Resident #1's negative statements, he was placed on one on one. Record review of a typed statement provided on 03/04/25 at 10:25 AM signed by the ADON and dated 08/12/24, indicated . I, [ADON's name], witnessed [Resident #1], walking outside the fenced area toward the parking lot at approximately 1615 (4:15 PM). Staff nurse was at opened glass door of courtyard visualizing resident as I approached him on foot in attempt to get him to return to the facility. He became physically and verbally aggressive stating that if I did not leave him alone, he would kill me. I got back into my car to follow beside him until other help arrived. I phoned the facility to ensure they were aware of what was happening. My car remained on the left and he was on the right. There was no oncoming traffic. [Resident #1] paused before crossing the highway while continuing to yell at me to stop following him. I continued to follow until the family arrived in their vehicle and persuaded him to get into their car. I at no time lost eyesight of resident, until he was placed in his private family car. The resident returned to the facility at approximately 1625 (4:25 PM) and was escorted back into the secured unit by family and DON and placed on 1:1 care. Record review of a typed statement provided on 03/04/25 at 10:25 AM signed by the DON and dated 08/12/24, indicated . Writer spoke to nurse [LVN B] to obtain statement of incident. [LVN B] stated he had been watching [Resident #1] on the courtyard and attempted to re-direct him back inside. He became belligerent so he stood at a safe distance in the doorway. When he walked away from the door, he ensured another staff member was present. [LVN B] stated he did not feel this was an elopement based on the fact the incident was witnessed. Interviews on 03/04/25 between 10:30 AM and 12:15 PM with (RN G, CNA L, Maintenance Assistant M, Director of Rehabilitation O, CNA N, LVN P, CNA Q, Housekeeping R, LVN S, LVN T, CNA U, LVN V, CNA W, Dietary Aide X, CNA Y, LVN Z, LVN AA, CNA BB, the Maintenance Supervisor, the ADON, COTA, MDS Coordinator, Activity Director and the Dietary Manager) revealed they were able to answer questions regarding abuse and neglect in-service, who to contact, when to contact and types of abuse. Staff was able to answer questions on elopement in-service regarding code pink, immediately contacting the Administrator and DON, searching facility on and off grounds, and calling the police if resident was not found within 30 minutes. During an interview on 03/06/25 at 09:55 AM, CNA H said she had worked on 08/12/24. She said she recalled Resident #1 being restless, had gotten out, and had walked down the road. She said everyone was looking for him. During an interview on 03/06/25 at 12:23 PM, LVN B said Resident #1 went outside and he had eyes on him at all times. He said he alerted management and DON when Resident #1 was outside of the fence, and they handled everything after that. LVN B said he had the back door open and contacted the DON by phone. LVN B said he was not sure if Resident #1 left the facility property. LVN B said he continued with his duties since he had other residents to take care of. He said the Maintenance Supervisor and the SW assisted with bringing him back. LVN B said he did not receive any education on documentation that he could recall. He said the facility staff tried to blame him for the incident that was why he became upset at them. He said he had kept them in the loop of Resident #1's behaviors. During an interview on 3/6/25 at 12:46 PM, the Maintenance Supervisor said the day of the incident, 08/12/24, someone (unsure of who) had asked him if he had seen Resident #1. He said he then started to coordinate people and started looking for him. He said he was able to get on the intercom with his phone and announced Resident #1 was missing. He said he helped the family bring him back from their car. He said to his knowledge, Resident #1 was missing. He said people left in their cars to search off ground. During an interview on 03/06/25 at 1:28 PM, the SW said there was a mass text indicating the ADON was following Resident #1. She said she had just gotten back to the facility, got back in her car and when she got to where Resident #1 was, which was by the school, Resident #1's family members were talking to him and were getting him in the car. She said they brought him back to the facility. The SW said she saw the hospice nurse in her car by the school as well. She said they spoke to each other. She said there was no mention that Resident #1 was missing. She said the ADON was with him and had had eyes on him. During an interview on 03/06/25 at 2:20 PM, CNA C said no one was constantly with Resident #1 on 08/12/24. She said the nurse was the one that did not see him, and he started calling the Administrator and putting the alert out that he was not where he was supposed to be. She said everyone started looking. CNA C said they did not know which direction he had gone but he had not gone very far. Record review of the elopement assessments completed for the 15 residents who resided in the secure unit were dated 08/13/24 and 08/14/24. Record review of 13 resident safe assessments completed on 08/12/24 with no concerns noted. Record review of 13 employee (CNA DD, CNA EE, LVN FF, LVN Z, CNA GG, CNA N, CNA L, [NAME] HH, LVN KK, the Treatment Nurse, MA LL, [NAME] MM, and the Dietary Supervisor, abuse and neglect questionnaire completed on 08/12/24 indicated staff was able to answer who to report abuse and neglect, when to report abuse or neglect, and the types of abuse. Record review of the in-services dated 08/12/24, indicated staff was in-serviced on elopement, code pink, best practice if a resident cannot be located, immediately contacting the Administrator, DON, regardless of the time or day of the week, and it was imperative to have sense of urgency in order to ensure resident safety, abuse and neglect, immediately contacting the Administrator, and types of abuse. Record review of weekly monitoring indicated Administrator/designee will interview 2 staff members a day 5 times a week for 4 weeks with a start date of 08/12/24 and end date of 09/06/24 had been completed. Record review of facility's policy Elopement with an effective date of 12/2017 indicated: Policy It is the policy of this home to provide a systematic approach to searching for a resident who may have left the home and/or home grounds. PROCEDURE The following steps are to be followed when a resident is noted absent and is not found on initial search of the home. This also includes when a resident leaves the home grounds without staff notification. Home Staff will: o Search the home and grounds o Send staff member(s) out to locate the resident o Notify Administrator or on-call person immediately o If resident is not located within 30 minutes, call the local police Charge Nurse will: o Notify responsible party (this may be done when the search is initiated) o Notify the resident's physician o Assess the resident on return to the home o Document the time resident absence is noted, time of return, assessment of resident, and notification of Physician and Responsible Party o Complete an incident report in the clinical software o Follow-up charting for 24 hours if no injuries: follow-up charting on injuries until resolved Administrative I Supervisory Staff will: o Determine if elopement is reportable to state regulatory agency o Interview staff and obtain written statements. If

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment including comfortable and safe temperatures for 5 of 6 residents (Resident #'s 1, 3,4,5 and 6) and 5 of 6 zones (Zone 6, Zone 5, Zone 5/11, Zone 5/7 and Zone 10) reviewed for environment. 1.The facility did not ensure facility temperatures were below 81 degrees Fahrenheit after a power outage on 6/16/23. Staff interviews corroborated the temperature in the building was up to 92 degrees on Saturday 6/17/23. Despite having a cooler area in the building for Residents to gather. Residents slept in their rooms exposed to higher temperatures for 4 days. 2. Resident #1 was hospitalized on [DATE] with signs and symptoms of heat exposure and dehydration. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 6/20/23. While the IJ was removed on 6/21/23, the facility remained out of compliance at actual harm that is not immediate with a scope identified as widespread, due to the facility's need to complete in-services and evaluate the effectiveness of the corrective systems. These failures resulted in actual harm to Resident #1 and could place the other residents at risk of heat exhaustion and dehydration. Findings included: Record review of Resident #1's face sheet indicated he was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including history of heart attack, high blood pressure, history of urinary retention, muscle weakness, history of urinary tract infections, BPH (Benign prostatic hyperplasia is also called an enlarged prostate which can impede urine flow) Type II diabetes, and Alzheimer's disease. Record review of Resident #'1 MDS dated [DATE] indicated he understood others and made himself understood. The MDS indicated he had severe cognitive impairment (BIMS of 5). The MDS indicated Resident #1 had no behavior of rejecting care. The MDS indicated he required extensive assistance with bed mobility, transfers, locomotion in his wheelchair, dressing, eating, toilet use and personal hygiene. The MDS indicated he was totally dependent on staff for bathing. The MDS indicated he had an indwelling catheter and was frequently incontinent of bowel. Record review of Resident #1's care plan did not specifically address maintaining a comfortable temperature. Record review of the Resident #1's nursing progress note dated 6/18/23 at 12:55 p.m., stated Noted when patient was in dining room, he was lethargic, pale, sweaty, not eating well, not drinking, even with encouragement the patient needed assistance to eat, taking bites. Patient was asked if he felt ok, he said no, I just don't feel good, I don't know why, when asked where he was he said (another city's name) BS (blood sugar) at 1125 (11:25 a.m.) was 208 and 4 units Novolog Sliding Scale. Notified (Resident's MD) we would transfer the patient to ER for evaluation. Left message on (family members) phone for return call. When the ambulance arrived the patient could not stand, he could answer their questions, but very slowly. Their first BP reading was 86/42. This note was written by LVN A. Record review of Resident #1's hospital History and Physical dated 6/18/23 at 4:50 p.m., stated his date of admission was 6/18/23 and his admission diagnoses included Heat exposure and Acute metabolic encephalopathy (metabolic encephalopathy is a disorder that affects brain function. It can be temporary or permanent, depending on the severity of the damage. This condition is mainly caused by other severe health concerns. These problems affect electrolytes and blood chemicals in the body, resulting in brain cell damage. It is a severe health condition that can cause structural brain damage if not treated well. Causes of metabolic encephalopathy include; exposure to toxic chemicals; certain medications; illicit drugs; organ failure; dehydration and malnutrition; Excessive alcohol consumption; thiamine deficiency; severe and constant fever) and acute cystitis (an infection of the bladder or lower urinary tract). The History and Physical stated, (Resident #1) was received from the EMS services with generalized weakness and fatigue. Per EMS (emergency medical services), nursing home staff called EMS due to patient being generally weak and lethargic. The nursing facility has not had power due to damage sustained in a storm 3 days ago, and patient has been exposed to increased heat since. EMS administered 1L (liter) IV (intravenous) fluids in route, and patient is his baseline mentation (mental activity) upon arrival in the ED (emergency department). Record review of the hospital lab results obtained on 6/18/23 showed Resident #1 had an elevated BUN of 28 mg/dl (Normal range is 9-20 mg/dl [blood urea nitrogen- Urea nitrogen is a waste product made when your liver breaks down protein. It's carried in your blood, filtered out by your kidneys, and removed from your body in your urine. An elevated BUN can mean the kidneys are not working well but also can be due to dehydration]). During an interview on 6/20/23 at 4:50 p.m. the hospital's Compliance Officer said Resident #1 was admitted to the hospital with signs and symptoms of dehydration and heat exposure. Record review of the facility floor plan updated 5/17/19, displayed the layout of the facility as a capital I. The back hall or top of the I was divided into 2 resident areas. The back left side of the hall - was labeled zone 11/5. The back right side of the hall was labeled zone 7/5. The center of the I was also a resident area and was labeled zone 5. There was a bump off to the right center of zone 5 labeled Zone 10 which was the dining area. The bottom of the I was divided into 2 areas; the far right of the hall was labeled zone 6 and was the secured resident unit of the building. The center and left of the bottom of the I was labeled zone 8. Record review of the facility census dated 6/15/23 indicated Resident #1 was roomed in room [ROOM NUMBER] on the center hall toward the back left (zone 5). Record review of the facility admit/discharge report indicated Resident #1 was roomed in room [ROOM NUMBER] on the center hall toward the back left (zone 5) just before his discharge from the facility on 6/18/23. During an interview on 6/19/23 at 12:55 p.m., the Regional Administrator said that a representative from the power company was at the facility at approximately 8:00 p.m. on 6/18/23 and had informed him the facility was expected to be up and running (power restored) at some point today (6/19/23). The Regional Administrator added, the statement from the power company representative was not a promise. During an interview on 6/19/23 at 1:30 p.m., the Administrator said the facility lost power at approximately 1:00 a.m. on 6/16/23. The Administrator said the facility's back up generator had kicked on upon the outage. The administrator said he had chosen not to evacuate the building because additional resources were coming to keep the building cool and if the facility evacuated the residents, they would have had to evacuate to another city, as many of the sister facilities had also been affected by the outage. He said the facility had maintained temperatures in the building from 72-82 degrees Fahrenheit since the outage to his knowledge. The Administrator said the secure unit (zone 6) and the back hall (zone 5/11 and zone 5/7) were warmer, but Residents were being kept on the front lobby/activity area (zone 8) where the temperature had been between 72-82 degrees. The Administrator said some residents have refused to come to the cool area (zone 8). During an interview on 6/19/23 at 1:40 p.m., the Maintenance Director said he had not kept any temperature logs for the facility since the power outage, so he could not accurately report what the temperatures in the facility had been since the outage. During an interview on 6/20/23 at 12:10 p.m., the EMTFD (Emergency Management Task Force Director)-Region 4, said he came to the facility on [DATE]. He said he offered evacuation on two occasions that day (6/17/23). The EMTFD said the first time he came to the facility on [DATE], one of the thermostats read 88 degrees Fahrenheit. The EMTFD said the Administrator declined the evacuation offer and reassured him the facility had additional generators and portable HVAC units to cool the building on the way. The EMTFD said the second time he came to the facility on [DATE], the Administrator met him on the front porch of the facility. The EMTFD said he was not invited into the building at that time. The EMTFD said he thoroughly explained to the Administrator that the evacuation services offered would be at no cost to the facility and that there was already space for the facility's residents at a local hospital. The EMTFD said he explained to the Administrator the facility would not lose any money while the residents were evacuees at the local hospital and would be able to continue to bill for services as the facility's staff would continue to provide care for the residents. The EMTFD said the Administrator insisted the residents were doing just fine and they had a cool area in the facility for the residents. During an interview on 6/20/23 at 2:05 p.m., LVN A said Resident #1 had a significant cognitive change on Sunday (6/18/23). LVN A said she had been to his room and taken his blood sugar at approximately 11:25 a.m. She said he was talking and seemed like his normal self. LVN A said he was not sweating profusely, nor did he have any complaints. LVN A said by 12:00 p.m. his whole demeanor had changed. LVN A said she saw him in the dining room, and he was sweating profusely and was not making any sense. During observations on 6/20/23 at 12:10 to 12:35 p.m., the facility temperatures on the Center Hall (zone 5) were 76 degrees F at the front of the hall and 85 degrees at the back of the hall. During observations on 6/20/23 at 12:35 to 12:40 p.m. facility temperatures on the back hall (zones: 5/11 and 5/7) were 85-86 degrees Fahrenheit. During observations on 6/20/23 at 12:50 p.m., in the front/ right hall (secured unit- zone 6) the facility temperature was 86 degrees Fahrenheit. During an interview on 6/20/23 at 12:55 p.m., the Maintenance Director said the facility's current 150 kw generator was not big enough to run additional AC units for the whole building. The Maintenance Director said the Power went out at 1:00 a.m. in the morning on Friday (6/16/23). He said the emergency generator came on immediately and fans were gathered and plugged in to keep areas cool. The Maintenance Director said portable HVAC units arrived early afternoon on Friday (6/16/23). He said window units arrived Saturday morning around 10:00 a.m. The Maintenance director said the large generator arrived Sunday (6/18/23) evening around 11:00 p.m. The maintenance director said without the larger generator the temperatures had been between 82- and 84-degrees Fahrenheit. During observations on 6/20/23 at 3:40 p.m. the front cool area (zone 8) temperatures were 78-79 degrees Fahrenheit. During observations on 6/20/23 at 3:40 to 3:41 p.m., facility temperatures on the Center Hall (zone 5) were 91-93 degrees Fahrenheit. During observations on 6/20/23 at 3:44-3:47 p.m., facility temperatures on the back hall (zones: 5/11 and 5/7) were 90- 93 degrees Fahrenheit. During observations on 6/20/23 at 3:45 pm the facility census 52 residents had all been moved to the front cool area of the building. During an interview on 6/20/23 at 3:47 pm the Administrator said all Residents were currently being kept in the front lobby. The Administrator reported all residents had been sleeping in their rooms since the outage. According to the website www.accuweather.com accessed on 6/20/23 the outside temperature on 6/20/23 at 4:16 p.m. was 99 degrees Fahrenheit with a heat index of 120 degrees. Record review of the face sheet for Resident #3 dated 6/20/23 indicated she was [AGE] years old, readmitted to the facility on [DATE] with diagnoses including heart failure, muscle wasting and atrophy, heart disease, and high blood pressure. Record review of the MDS dated [DATE] indicated Resident #3 usually made herself understood and usually understood others. The MDS indicated she had severe cognitive deficit (BIMS of 4). The MDS indicated she required limited assistance with most ADLS (bed mobility, Transfers, dressing, toilet use, bathing and personal hygiene) but did require extensive assistance with locomotion in her wheelchair on the unit. During an interview and observation on 6/20/23 at 1:00 p.m., Resident #3 laid in her bed on the back hall (zone5/7) with a cold washcloth on her face. Resident # 3 said she was hot. Resident #3 said she had been in the front of the building and wanted to go back up there. Record review of Resident #4's face sheet indicated she was [AGE] years old admitted to the facility on [DATE] with diagnoses including, history of hypertensive urgency muscle wasting and atrophy, muscle weakness, diabetes, high blood pressure, and history of stroke. The MDS indicated she required supervision only with ADLS except for bathing for which she required limited assistance. Record review of the MDS dated [DATE] indicated Resident #4 understood others and made herself understood. The MDS indicated she had no cognitive impairment (BIMS of 13). During an interview and observation on 6/20/23 at 1:10 p.m., Resident #4 was sitting in a wheelchair in her room on the back hall (zone 5/11). Resident #4 said she was about to go back to the front of building because it was a little cooler up there. Resident #4 said she slept up there on the couch (in the front lobby area zone 8) last night because it was just too hot in her room and said she was dripping with sweat. Record review of Resident #6's face sheet dated 6/20/23 indicated he was [AGE] years old admitted to the facility on [DATE] with diagnoses including history of metabolic encephalopathy, back abscess (a swollen area within body tissue, containing an accumulation of pus.), history of GI hemorrhage (Gastrointestinal (GI) bleeding is any type of bleeding that starts in the GI tract, also called the digestive tract), high blood pressure, history of skull fracture, history of traumatic brain injury, Type II diabetes, and dysphasia after stroke. Record review of the MDS dated [DATE] indicated Resident #6 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11 ). The MDS indicated he required supervision only with most ADLS except for bathing for which he was totally dependent on staff. During an interview on 6/20/23 at 3:00 p.m. Resident #6 was sitting in his wheelchair in the front lobby area (zone 8). He said the temperature up here was not terrible and was much better than it was over the weekend. Resident #6 said he did not know what the actual temperature was over the weekend but said it was real hot. Resident #6 said he had not been able to sleep much because it was just too hot in his room on the back hall (zone 5/11). Record review of Resident #5's face sheet dated 6/20/23 indicated he was [AGE] years old readmitted to the facility on [DATE] with diagnoses including COPD, Schizoaffective disorder, bradycardia, muscle wasting and atrophy, history of left knee replacement, and chest pain. Record review of the MDS dated [DATE] indicated Resident #5 understood others and made himself understood. The MDS indicated he had moderate cognitive impairment (BIMS of 11). The MDS indicated he required supervision with ADLS except for bathing for which he was totally dependent on staff. During an interview on 6/20/23 at 4:16 p.m., Resident #5 was sitting in the front lobby area (zone 8). Resident #5 said he has had increased trouble breathing with the heat and has not been able to sleep since the outage. He said it was just too hot to get any sleep. Resident #5 said it helped to sit up here (in the front [zone 8]) but at night, he said residents go back to the rooms to sleep and it's just too dang hot to sleep on the back hall (Zone 5/7). During an interview on 6/20/23 at 11:56 a.m., CNA B said she worked at the facility Friday (6/16/23) morning from 6am to 2pm. She said the power had gone out sometime before her shift started but was not sure what time. CNA B said it was very hot in the building. CNA B said it was hotter in the back of the building than it was in the front of the building. CNA B said she could not say what the thermostats read on the resident halls during her shift. CNA B said she remembered looking at the thermostat in the dining room when the residents were eating lunch and it said 93 or 94 degrees Fahrenheit. She said it was very hot and the facility was gathering fans at that time. CNA B said there were no portable HVAC units in the building at the time (6/16/23 from 6am to 2pm). During an interview on 6/20/23 at 12:09 pm MA C said she worked Friday (6/16/23) and it was awful. MA C said it was awful because it was so hot in the building. MA C said she did not recall what the thermostats said in the building. During an interview on 6/20/23 at 12:12 p.m., CNA D said she worked in the facility on Saturday (6/17/23) and Sunday (6/18/23). CNA D said it was very hot in the building all weekend. CNA D said she did have some residents compliant to her about the heat but could not recall their names. CNA D explained she worked for a staffing agency and was not extremely familiar with the residents. CNA D said she was told an additional generator was coming to help cool the building. CNA D said she heard the nurses saying that a big generator was coming to help cool the building, so that was what she told residents. CNA D said the big generator did not come until Sunday night. CNA D said she heard there was some delay with getting the generator started on Sunday night due to some of the cords needed had not arrived. CNA D said she was not sure what time the big generator was up and running Sunday night. CNA D said the front of the building (zone 8) was just as hot as the rest of the building Saturday (6/17/23) and Sunday (6/18/23). CNA D said the thermostat to the immediate left when entering the back hall (zone 5) on Saturday between 4:00 p.m. and 5:00 p.m. read 92 degrees Fahrenheit. On Sunday (6/18/23) CNA D said the same thermostat read between 80-85 degrees Fahrenheit during her 2:00 p.m.-10:00 p.m. shift. During an interview on 6/20/23 at 12:20 pm the ADON said she came home early from her vacation on Saturday (6/17/23) to help out at the facility. The ADON said she worked as the medication aide that day. The ADON said it was hot in the building but not unbearable. The ADON said there were fans up and running throughout the building but said she could not say if there were any portable HVAC systems in the building at that time. The ADON said she also came in Sunday to help out. The ADON said no residents complained to her about the heat. The ADON said she knew the idea of evacuation was mentioned but never heard any actual plan. The ADON said the DON was on vacation herself and could not be reached. The facility Emergency preparedness plan reviewed on 7/22/21, Emergency Preparedness Plan Loss of Power Heat and Water , stated . (2) Loss of Comfort Heating/Cooling .(b) If loss is in the entire home due to interruption of public utilities (electrical /natural gas) and residents become uncomfortable, they will be placed in the beds and protected by an adequate supply of linen, or they will be moved to a central location that can be heated/cooled. (c) If loss is for extended period of time and the residents can no longer be protected in a comfortable manner, the residents will be evacuated to another location . The Administrator was notified on 6/20/23 at 5:33 p.m. that an Immediate Jeopardy situation was identified due to the above failures. The Administrator was provided the Immediate Jeopardy template on 6/20/23 at 5:37 p.m. The facility's Plan of Removal was accepted on 6/21/23 at 2:20 p.m., and included: Immediate Action Taken Resident Specific o All residents assessed on 6/20/23 at 1830 [6:30 p.m.]by licensed nurses (MDS Coordinator and ADON) for signs or symptoms of heat exhaustion and dehydration. Findings documented on the Resident Monitoring Form, and reviewed by RN (Regional Nurse.) No residents in the facility currently display any signs or symptoms of heat exhaustion and dehydration. o All residents were moved to the front lobby area of the facility, on 6/20/2023. As of 1340 on 6/20/2023, no residents remained in their rooms. The temperature of the front lobby area remained at 78-79 degrees. Residents returned to their rooms 6/20/2023 by 2330, once the temperature in the facility was below 80 degrees. o Residents are being provided cool beverages, meals and snacks as desired. Fluids are being offered every 2 hours and being documented on the Resident Monitoring Form. Residents unable to make their own decisions are automatically given fluids. This practice will increase in frequency to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. o MD notified of the IJ on 6/20/2023 at 1815 by Regional Nurse, no new orders received . System Changes o Licensed nurses assessing residents every 2 hours for signs and symptoms of heat exhaustion or dehydration, and documenting on the Resident Monitoring Form. Family and MD will be notified of any signs of symptoms of heat exhaustion or dehydration. Residents are currently in an area where temperatures do not exceed 79 degrees This practice will increase in frequency to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. o Licensed nurses checking vital signs and offering fluids every 2 hours and documenting on the Resident Monitoring Form. Residents are currently in an area where temperatures do not exceed 79 degrees. This practice will increase in frequency to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. o Temperature Log initiated for each occupied resident room. Maintenance Director or Licensed Nurse to use hand held thermometer and document temperature of each occupied resident room on a census each hour. o Obtained 6 porta-coolers on 6/17/2023 at 1300. These are stationed throughout the facility. o 6 porta-coolers - Secured unit, 2 dining room, 2 private hall, long hall o Obtained 5 portable generators and 4 commercial fans on 6/18/2023 between 0100 and 1200. These were used to power 6 window unit air conditioners through out the facility. o 5 portable generators - secured unit dining room, 3 in main dining room, day room in the rear of the building o 6 window units - secured unit dining room, 4 in main dining room, day room in the rear of the building o 4 commercial fans - 2 in the lobby, long hall, middle hall o Obtained an industrial 120kw generator on 6/18/2023 at 1930. This supplied air conditioning to middle hallway and lobby area. o Obtained a 60kw generator on 6/20/2023 at 1700. This supplied air conditioning to the dining room and the secured unit hallway. o Facility purchased 21 personal battery operated fans for resident use on 6/20/23 at 1400. o Facility in process of obtaining 8 additional porta-coolers. These items currently en route to the facility, expected by 2100 on 6/20/2023. o Facility now has an additional industrial 300kw generator at the facility, as of 2015 on 6/20/2023. This generator now providing electricity to the entire facility, including the HVAC systems. Education o Regional Nurse providing education to all staff regarding signs and symptoms of heat exhaustion. All staff present in the facility were educated on 6/20/2023, at 1830. Staff not present for the education will receive the education prior to their next shift. o Regional Nurse providing education to all staff regarding signs and symptoms of dehydration. All staff present in the facility were educated on 6/20/2023, at 1830. Staff not present for the education will receive the education prior to their next shift. o Regional Nurse providing education to licensed nurses regarding Resident Monitoring Form, and the frequency to complete. This is the form that resident vitals, signs and symptoms of heat exhaustion or dehydration, offering fluids will be documented on. All licensed nurses in the facility were educated on 6/20/23 at 1830. Licensed nurses not present for the education will receive the education prior to their next shift. Regional Nurse providing re-education to licensed nurses regarding Resident Monitoring Form, and the frequency to complete. The frequency is currently every 2 hours. The frequency will increase to every 30 minutes, if the facility experiences loss of power during an extreme heat advisory. The frequency information is included in this education. This is the form that resident vitals, signs and symptoms of heat exhaustion or dehydration, offering fluids will be documented on. All licensed nurses in the facility are currently being educated as of 6/21/2023 at 12:15pm. Licensed nurses not present for the education will receive the education prior to their next shift. o Regional Nurse providing education to Maintenance Director and Licensed Nurses on hourly temperature logs for each occupied resident room. Maintenance Director and licensed nurses on duty educated on 6/20/23 at 2110. All licensed nurses not present for the education will receive the education prior to their next shift. o Regional Director of Operations educated Administrator on emergency procedures and reporting changes and displaced residents on 6/20/23 at 2110. o Facility Disaster/Emergency Plan reviewed and updated on 6/21/2023 at 0830, to include Should building be unable to maintain temperatures between 71 - 81 degrees, the evacuation plan will be initiated. Corporate will ensure HHSC, local emergency management systems, families and Medical Director are notified. Monitoring o Administrator/designee to review Temperature Logs 3 times per day until power is restored and facility temperatures are at 80 degrees or below. Findings are to be reported to Regional Director of Operations. Should temperatures exceed 80 degrees, HHSC will be notified. DON/designee to review the Resident Monitoring Form with Vitals 2 times per day until power is restored, and facility temperatures are at 80 degrees or below. If any resident assessed has any indication of heat exhaustion or dehydration the physician/DON/designee will be notified On 6/21/23 the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: The arrival of the large 300 kw generator at the facility was observed by the surveyors on 6/20/23 at approximately 8:30 p.m. The system was up and running and providing electricity to the entire facility, including the HVAC systems throughout the building. Resident rooms were spot checked for cool air coming out of the vents and falling temperatures were verified by surveyors before exiting the building on 6/20/23 at approximately 10:45 pm. Record review of Facility Temperature logs dated 6/20/23 at 11:00 p.m. confirmed Resident room temperatures in all zones were below 80 degrees Fahrenheit. (73.2 to 79). Record review of the Facility Temperature Logs dated 6/21/23 revealed all occupied resident rooms had a temperature check hourly starting at 12:00 a.m. All room temperatures were below 80 degrees. Record review of the untitled Facility log indicated residents were assessed for signs and symptoms of heat exhaustion and dehydration, vitals obtained, and fluids offered (with the exception of those residents asleep during sleep hours) every two hours starting on 6/20/23 at 6:30 p.m. During an interview on 6/21/23 at 8:34 a.m., Resident # 6 said he slept so much better last night. During an interview on 6/21/23 at 11:02 a.m. Resident #5 reported he slept good last night and was breathing better. During Observations from 11:40 a.m. to 3:47 p.m., surveyors continued to monitor temperatures in the facility. Initially, elevated temperatures were obtained in the facility dining area/ Kitchen of 81 degrees (in the dining room) and 91 degrees (in the kitchen). The facility responded by obtaining additional portable HVAC units for those areas. After the HVAC units were placed temperatures in the dining room and kitchen were 78 degrees (in the dining room) and 78-81 degrees (in the kitchen). All resident occupied areas and rooms checked were found to be between 71-79 degrees Fahrenheit. In-service sign in sheets over Checking the temperature of Resident Rooms hourly, Resident Monitoring Form to be completed every 2 hours, signs and symptoms of dehydration and signs and symptoms of heat exhaustion were reviewed. The In-service sign in sheet for the Administrators direct in-service over Emergency preparedness was reviewed. Record review of the updated Facility Disaster/Emergency Plan stated Should building be unable to maintain temperatures between 71 - 81 degrees, the evacuation plan will be initiated. Corporate will ensure HHSC, local emergency management systems, families and Medical Director are notified. During staff interviews on 6/21/23 from 2:11p.m. to 3:13 pm the following clinical staff were interviewed (MA C, RN E, CNA F, LVN G, CNA H, LVN I, CNA K, LVN L, LVN M, CNA O, LVN P, MA Q, LVN R, RN S, CNA T, and the ADON [On the 6:00 a.m. to 2:00 p.m. shift 2 nurses, the ADON, 2 MAs and 2 CNAs; on the 2:00 p.m. to 10:00 p.m. shift 3 nurses, 7 CNAs and 1 MA; and on the 10:00 p.m. to 6:00 a.m. shift 3 nurses and 1 CNA]. During these interviews CNAs and MAs said they had been in-serviced over Checking the temperature of Resident Rooms hourly , Resident Monitoring Form to be completed every 2 hours, signs and symptoms of dehydration (feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong smelling urine, decreased urination) signs and symptoms of heat exhaustion elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps). They indicated if any resident displayed s/s of heat exhaustion or dehydration during rounds they would immediately report it to the nurse. During these interviews nurses said they had been in-serviced over Checking the temperature of Resident Rooms hourly, Resident Monitoring Form to be completed every 2 hours, signs and symptoms of dehydration (feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong smelling urine, decreased urination) signs and symptoms of heat exhaustion (elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps). The nurses said if they observed, or it was reported to them that any residents had s/s of heat exhaustion or dehydration they would immediately notify the physician and DON. During an interview on 6/21/23 at 2:30 p.m., the Administrator correctly listed s/s of heat exhaustion and dehydration (elevated body temperature, hot, red, dry or damp skin, headache, dizziness, nausea, confusion, heavy sweating, cold pale or clammy skin, elevated heart rate, muscle cramps/ feeling thirsty, Lightheaded, tiredness, dry mouth, dark colored or strong-smelling urine, decreased urination). He said Resident rooms will continue to be checked every hour to ensure temperatures are maintained. He said if there was failure of the generators powering the HVAC units the temperature checks will be done every 30 minutes. The Administrator said Residents are being assessed by the nurses every 2 hours which included a full set of vital signs. The Administrator s [TRUNCATED]

Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for 1 of 6 residents (Resident #1) reviewed for smoking safety. RN A did not ensure Resident #1 was not using Oxygen while smoking. RN A lit a cigarette for Resident #1 while Oxygen was on and being delivered thought a nasal cannula causing second degree burns to Resident #1's face. An Immediate Jeopardy (IJ) situation was identified on 04/30/23 at 2:15 p.m. While the IJ was removed on 05/01/23, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of physical harm, mental anguish, emotional distress, or death. Findings included: During an observation and interview on 04/29/23 at 10:25 a.m. Resident #1 had a large fluid fill blister, white in color, on his right cheek that extended to the top of his upper lip. There was another fluid filled blister on the right side of his nose that extended to the tip of his nose. Facial hair on his right upper lip appeared to be shorter than the left side of his lip. Resident #1 said he was not in pain. He said he was smoking the night before (04/28/23) and did not realize that Oxygen was flammable. He said he was wearing his Oxygen while smoking. He said he normally does not have his Oxygen on while smoking and does not use Oxygen all the time. He said while smoking the Oxygen caught fire. He said it was storming and he thought at first it was a lightning flash. He said RN A was there and quickly put out the flame. (Within a few seconds) He said he went to the doctor the next day. (04/29/23). He said he did not feel he was abused or neglected. Record review of face sheet dated 04/30/23, indicated Resident #1 was a [AGE] year-old male, last admitted on [DATE] and his diagnoses included Transient cerebral ischemic attack, (a stroke that lasts only a few minutes), hypertension, Dyspnea (Shortness of Breath), dementia, cognitive communication deficit, muscle weakness, Bipolar disorder, Chronic obstructive pulmonary disease (COPD), schizoaffective disorder (a mental health problem where you experience psychosis as well as mood symptoms), and Pulmonary hypertension (A type of high blood pressure that affects the arteries in the lungs and the right side of the heart). Record review of consolidated physician orders dated 02/26/23, reflected Resident #1 may have O2 2L/min via NC PRN for oxygen sat below 92%. Every shift Days 6:00 AM - 2:00 PM, Evenings 2:00 PM - 10:00 PM, and Nights 10:00 PM - 6:00 AM. Record review of MDS dated [DATE] indicated Resident #1 was able to express ideas and wants, was alert to person, place, and time, was able to understand others, and was cognitively intact. Resident #1 required supervision and set-up assistance of 1 person for all ADLs other than hygiene where he required assistance of 2 persons. He was able to transfer independently and used a wheelchair. Record review of Resident #1's care plan initiated 12/19/22 and revised on 04/30/23 indicated he was a smoker and at risk of injury. He was to wear a smoking apron during smoke breaks. Staff were to supervise him during smoking. The care plan was updated on 04/29/23 to show staff are to ensure that resident is not in the smoking area with Oxygen tank or tubing/nasal canula. Record review of progress note dated 04/28/23 at 06:40 p.m., RN A recorded he went to the smoking area to observe resident smoke break. Resident #1 was already outside with his smoking apron on. Cigarettes were handed out and lit. RN A did not recognize Resident #1 had Oxygen on. A small flame was extinguished, and Oxygen was turned off. Resident #1 was assessed for injuries with left cheek and nose light pink with no open areas or blisters noted. Resident #1 denied pain. Resident sitting up at nurse's station with no signs of distress. The Responsible party and physician were notified. There were no new orders from the physician. Record review of an incident report dated 04/29/23, completed by the administrator indicated on 04/28/23 at 6:30 p.m., Resident #1 was smoking in the designated smoke area when RN A lit his cigarette while he was wearing oxygen. The Oxygen flashed causing his beard to singe. The next morning at 10:00 a.m. redness and blistering was discovered to Resident #1's face. The Doctor was notified and new orders for Silvadene (silver sulfadiazine) cream 1% to be applied to the affected area once a day were received. Resident #1 was sent to the hospital on 04/30/23 for evaluation and returned the same day with no new orders. Record review of progress note dated 04/29/23 at 11:30 a.m. reflected LVN A recorded she contacted the physician to report a need for wound care orders to Resident #1's face after a smoking incident last evening. The Nurse reported areas of burns and appearance of areas of concern. New orders were received of Silvadene (silver sulfadiazine) cream 1% once a day. The Resident reports no pain/discomfort in area currently. Record review of progress note dated 04/29/23 at 3:16 p.m. reflected the DON recorded she noticed Resident #1 to have newly onset and slight difficulty breathing. Upon further assessment, swelling was noted to Resident #1's right inner nare (Opening of the nose). The Physician was contacted with orders to send to hospital for evaluation. Record review of hospital records dated 04/29/23 indicated Resident #1 was seen at the hospital for facial burn. Diagnosis was Facial burn, second degree (Involves the top two layers of the skin, might have blisters over the burn area. The burn may leave a scar). New orders to gently clean with soap and water and apply bacitracin (topical antibiotic ointment) were received. Follow-up was to be scheduled by facility staff. Review of progress note dated 04/29/23 at 4:58 p.m. Resident #1 returned from the emergency room with new orders for bacitracin ointment, apply BID. The Physician was contacted and ordered to discontinue bacitracin and continue with Silvadene as previously ordered. The Resident continues to have difficulty breathing through nose. No distress was noted. (After return from hospital) The Resident is at nurses' station currently. Resident #1 states He can breathe though his nose and that is does not hurt to breathe. During an observation and interview on 04/29/23 at 10:45 a.m. six residents was observed in the smoking area including Resident #1. Three of the residents were wearing smoking aprons including Resident #1. There were no Oxygen tanks in the smoking area. The fire extinguisher was available and last serviced April 2023. Ash trays were appropriate for safety. Residents were being supervised by a nurse. Resident #2 said she was present when Resident #1's Oxygen ignited on 04/28/23 around 6:30 p.m. She said RN A was helping her to her table and Resident #1 was already in the smoking area with his safety apron on when she arrived. She said after RN A assisted her to her normal table and Resident #1 was sitting behind her. She said it was storming and darker than usual. Resident #1 asked RN A to light his cigarette. She said RN A turned around, lit Resident #1's cigarette and turned and lit hers. She said the next thing she knew, there was a flash. She said she thought it was a lighting flash, but she saw there was a flame at Resident #1's face. She said RN A quickly turned and extinguished the flame. She said they all went back inside the building and RN A took Resident #1 to his room. During an interview on 04/30/23 at 9:45 a.m., the Administrator said on 04/28/23 at 6:30 p.m., RN A was taking residents out for a smoke break. Resident #1 was already in the smoking area with his apron on when RN A arrived with 2 other residents. The Administrator said RN A lit Resident #1's cigarette without noticing he had his Oxygen on. The Administrator said RN A was assisting the two other residents when Resident #1's Oxygen ignited and singed Resident #1's facial hair. The Administrator said RN A immediately responded and assessed Resident #1 for injury. The Administrator said there was some redness to Resident #1's cheek and nose. There were no other injuries found at that time. The Physician, family, and Administrator were notified of the incident. The Administrator said he asked questions about the incident, and it was determined that the incident was not a reportable incident at the time, because there was no major injury to Resident #1. The Administrator said the next morning (04/29/23) around 10:00 a.m. during an assessment LVN A, found blisters to Resident #1's face. The Administrator said all residents were re-assessed for Smoking Safety and RN A was suspended pending investigation. The Administrator said RN A should have monitored to ensure there was no Oxygen in the area prior to lighting a cigarette. The Administrator said it is the policy of the facility that Oxygen should not be within 50 feet of the smoking area. During an interview on 04/30/23 at 9:45 a.m. the DON said RN-A should have noticed that Resident #1 was using Oxygen and should have not lit any cigarettes before making sure there was no Oxygen in or near the area. The DON said it is the facility policy that Oxygen should not be within 50 feet of the smoking area. The DON said Residents are not allowed to have Oxygen in the smoking area whether it is on or off. The DON said all Oxygen should be left inside the building or in the resident's rooms. DON said there are ten residents who smoke and out of those ten residents, six use Oxygen. During an interview on 05/01/23 at 4:10 p.m., RN A stated he was working as a charge nurse on 04/28/23 on the 2:00 PM to 10:00 PM shift. RN A said at 6:30 PM, he took three residents out for a smoke break. He said when he arrived at the smoking area, Resident #1 was already outside in the smoking area with his safety apron on. He said he assisted the other two residents outside. RN A said he was standing at the table and Resident #1 was behind him. He said Resident #1 asked him to light his cigarette. He said he turned around and lit the cigarette for Resident #1. RN A said he did not notice Resident #1 had his nasal canula under his nose and did not know his Oxygen was on. RN A said he should have checked before lighting the cigarette, but he did not. He said it was only a few seconds when he saw a flame and turned around and put out the fire. RN A said he assessed Resident #1 and Resident #1 said he was not in pain. RN A said he immediately ended the smoke break, and all three residents went back inside. RN A said he took Resident #1 to his room so he would assess him better in the light. RN A said he observed some pink areas to Resident #1's nose and cheek, but there was no blistering. RN A said he asked Resident #1 to stay at the nurse's station so he could keep an eye on him. RN A said he notified the ADON, who said she would notify the Administrator and DON. RN A said he called the doctor and reported the incident with no new orders. RN A said he got off at 10:00 PM and there were no blisters when he ended his shift, and the area was a light pink. RN A said he was notified by the ADON the next morning that blisters had formed on Resident #1's nose and cheek. RN A said this was the first time he knew about the blistering. RN A said he was suspended at the time and was informed today (05/01/23) at 1:40 p.m., that he was being terminated. RN A said he felt bad about what happened, and he should have seen Resident #1 had his Oxygen on in the smoking area. RN A said he had been a nurse for [AGE] years and had never hurt a resident and he felt horrible. RN A said it was his fault. During an interview on 04/30/23 at 10:45 a.m., Resident #2 said she was in the smoking area on 04/28/23 at 6:30. She said there were three residents in the smoking area at the time. Resident #2 said RN A had taken them out for the break. Resident #2 said Resident #1 was already in the smoking area with his apron on when they arrived. Resident #2 said RN A assisted her to the table, turned and lit Resident #1's cigarette. Resident #2 said she saw a flash and thought it was a lighting flash because it was storming at the time, until RN A turned around and put out the flames on Resident #1's face. Resident #2 said RN A took all three residents including Resident #1 into the building. Resident #2 said she had never seen other residents using oxygen in the smoking area. Review of the facility's smoking policy dated 01-2023 showed . It is the policy of this home that: * All residents who smoke will be supervised. * Smoking will be permitted in designated safe area(s) only. * Oxygen equipment is not permitted in the smoking area(s). The minimum safe distance for Oxygen equipment from the smoking area is 50 feet . The facility was notified of the Immediate Jeopardy on 04/30/23 at 2:15 p.m. and the Administrator was provided the Immediate Jeopardy template. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 05/01/23 at 1:44 p.m. and reflected the following: Plan of Removal - F 689 Accidents & Supervision Immediate Action Taken - Resident Specific o Small flame extinguished, and oxygen immediately removed. o Resident #1 was assessed for injury on 4/28/2023 at 6:40 p.m. by RN with no open areas or blisters noted. o MD notified of the incident on 4/28/2023 at 6:40 p.m. by RN, no new orders received. o Resident #1 noted to have open areas to face on 4/29/2023 10:00 a.m., MD notified and new orders for wound care received and implemented. o Resident #1 sent to ER for evaluation on 4/29/2023 at 3:16 p.m. and returned on 4/29/2023 at 4:58 p.m. with no new orders received. System Changes o Safety checklist implemented to be filled out with each smoke break. Staff member responsible for supervising the smoke break will complete this checklist once all residents are outside, prior to lighting any cigarettes. - completed 4/29/2023 o Updated smoking safety assessments performed by DON and Social Worker, done for all residents that smoke - completed 4/29/2023 o Updated BIMS assessments done on all residents that smoke, to assess cognitive function - completed 4/29/2023 o All care plans of residents that smoke reviewed and updated as needed to reflect current smoking needs, safety needs, and oxygen use - completed 4/29/2023 o Smoking Areas inspected, by administrator to verified that all smoking safety equipment in place and properly functioning - completed 4/29/2023 o Any oxygen tanks/tubing that are removed prior to entering the smoke area, will be stored inside the building, in an oxygen tank holder and/or in the resident's room. o Once all residents are outside and ready for smoke break, safety checklist will be completed. Then staff will safely light each individual's cigarette and remain outside during the entire duration of the smoke break. Education o Director of Nursing providing education to all staff regarding smoking safety and oxygen use, as well as abuse/neglect. Any staff member not present on 4/30/2023, will receive the education prior to working their next shift. o Director of Nursing providing education to all staff regarding Smoking Safety Checklist, including when it is to be completed (prior to any cigarettes being lit.) Any staff not present on 4/30/2023, will receive the education prior to working their next shift. o Social Services Director providing education to all smokers with the ability to understand, regarding smoking safety and oxygen use. Any resident that smokes that is not in the facility on 4/30/2023 will receive the education upon their return, prior to the next smoke break. Monitoring o Administrator/designee to review Smoking Safety Checklist 5 times per week for a minimum of 4 weeks to ensure any necessary interventions occurred. QAPI team to review monthly and make changes as needed. o Administrator/designee to randomly supervise 1 -2 smoke breaks a day, 5 times a week, for a minimum of 4 weeks to ensure that required safety interventions are in place, and initial Smoking Safety Checklist. QAPI team to review monthly and changes as needed. On 05/01/23, the surveyors confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by: Observations, interviews, and record reviews were conducted on 05/01/23 from 2:30 p.m. through 4:20 p.m. and included 4 other alert residents,(Not including Resident #1) nurses including 3 RN, 3 LVNs, Social Worker, ADON, Housekeeping Supervisor, and DON. Staff were able to identify residents requiring supervision while smoking and the need for aprons and protective equipment. Staff were able to confirm that only licensed nurses can supervise residents during smoking breaks and Nurses had been trained on completing the smoking check list prior to starting smoke breaks. Nursing Staff provided appropriate resident supervision during smoke breaks. There were no observed concerns. Staff were able to discuss the required level of staff assistance for residents in the smoking area and the requirement for Oxygen not being allowed in the smoking areas. Show knowledge of only licensed nurses are allowed to supervise Residents during smoke breaks. All residents who smoke were assessed for safety needs including BIMS and smoking safety assessments were completed by Social Worker and DON. Staff were using the Smoking check list prior to starting smoking break. Staff were able to identify the Abuse Coordinator, indicated reporting was immediate to the charge nurse or administrator and were able to give example of physical, verbal, sexual abuse and immediate intervention procedures. Nursing staff were in-serviced on monitoring residents during smoking breaks, completing smoking safety check, Storing Oxygen, and Abuse/Neglect. The training was completed on 04/29/23 and is ongoing. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. Staff were in-service on abuse and neglect. The training was completed on 04/29/23. Staff who were unavailable and not in-serviced were on a list to receive training prior to their next scheduled shift. There were no additional allegations of abuse or smoking incidents identified during the investigation. No residents indicated they were afraid during care or had complaints of their care. The facility Administrator and the DON will continue to monitor smoking areas as shown in the Plan of Removal and will ensure all residents are safe in the smoking area. were provided education on abuse/neglect on 04/29/23. On 05/01/23 at 4:24 p.m., the Administrator was informed the IJ was removed; however, the facility remained out of compliance at actual harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on interviews and record reviews the facility failed to ensure residents were free from significant medication error for 1 of 6 residents reviewed for administration of medication. (Resident #1) RN A administered the wrong medication (Neurontin 900 mg and [MEDICATION(S)] 25 mg.) to Resident #1. Resident #1 had a [CONDITION(S)], was admitted to the hospital for somnolence (state of being drowsy or sleepy) adverse effect of drug and [CONDITION(S)]. This was determined to be past non-compliance with actual harm due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place residents requiring assistance with medication administration at risk for adverse effects. Findings included: A face sheet dated 03/18/21 and consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 was discharged to an acute care hospital on 03/16/21. The MDS dated [DATE] indicated Resident #1 had severely impaired cognition, required supervision in walking, eating and extensive assistance in bed mobility, transfer, dressing, toilet use and personal hygiene. A care plan dated 11/13/20, indicated Resident #1 had the potential for side effects related to [CONDITION(S)] medications and use of anti- psychotic. Nursing staff were to administer medications as ordered, monitor and record side effects of medication, notify physician and family as needed regarding concerns. She was a fall risk due to the use of anti-anxiety and anti-depressant medications; unsteady gait and balance, generalized weakness and poor safety awareness. A Provider Investigation Report dated 03/17/21 showed the administrator reported Resident #1 was given the wrong medication and was sent to the hospital. Hospital records dated 03/16/21 at 6:44 p.m. indicated Resident #1 was brought to the emergency department for onset of [CONDITION(S)]. Patient (Resident #1) was accidently given the wrong medication earlier today. (900 mg of [MEDICATION(S)] (Neurontin) and 25 mg of [MEDICATION(S)]) Patient has been sleeping most of the day and lethargic. Nursing discussed with Poison Control and patient can be discharged home when awake enough to pass PO (swallow pill orally) challenge. Patient was admitted to the hospital 03/16/21 at 9:33 p.m., for Somnolence (sleepiness) adverse effect of drug, initial encounter, bacteriuria, mild dehydration and [CONDITION(S)]. During an interview on 03/18/21 at 2:30 p.m. RN A said he was the charge nurse for the secure unit on 03/16/21 from 6 a.m. to 2 p.m. RN A said he had prepared medications for a resident. (Neurontin 900 mg and [MEDICATION(S)] 25 mg.) RN A said Resident #1 had not been prescribed either medication. RN said at 11:55 a.m. he accidently gave the medications to Resident #1. RN A said he made the error because he was distracted when getting another resident's medication ready. He had to stop and handle an argument between Resident #1 and some other residents. When he went back to the med cart, Resident #1 was on his mind, and he gave the meds to Resident #1 by accident. RN A said he immediately realized what he had done, however, Resident #1 had already taken the medication. RN A said he reported the error to the physician, DON and family. The RN said he monitored Resident #1 and she slept until the end of his shift. RN A said he told the oncoming nurse (LVN A) to closely monitor Resident #1 for effects of the medication error. During an interview on 03/18/21 at 3:25 p.m. LVN A said she was the charge nurse for the secure unit on 03/16/21 from 2 p.m. to 10:00 p.m. LVN A said RN A told her to monitor Resident #1 because he had given her the wrong medication. LVN A said Resident # 1 slept on the sofa next to the nurse's station until staff woke her to assist in eating. LVN A said at 5:55 p.m. she saw Resident #1 red-faced and shaking for about 15 seconds. LVN A said Resident #1 started snoring when lowered to the floor. LVN A said 911 was called for emergency transport to the local hospital. During an interview on 03/18/21 at 3:40 p.m. the nurse practitioner said he monitors Resident #1 [CONDITION(S)] medications. The nurse practitioner said he did not know if the medication error caused Resident #1 to have a [CONDITION(S)], but he recently increased the dose of [MEDICATION(S)] (Bupropion) for Resident #1. (used to treat psychotic disorder with delusions due to known physiological disturbance) and the change in medication could have lowered Resident #1's threshold for seizures. Facility policy on medication dated 12/2017 showed: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The surveyor determined the facility was in non-compliance on 03/16/20 through 03/19/20 and took the following actions to correct the non-compliance: During an interview on 03/19/21 at 1:15 p.m. the administrator said plan of correction to ensure medication will be given as prescribed had been implemented which includes training for all nursing staff. Administrator said the medication error will be placed on the agenda for the QAPI (Quality Assurance and Performance Improvement) meeting for March 2021 and the plan will be monitored by the QAPI team. During an interview on 03/19/21 at 11:05 a.m. ADON (assistant director of nursing) said on 03/17/21 she conducted training for all nursing staff on administering medication. ADON said the training included ensuring medication is given to the right resident. ADON said RA A was required to take additional on-line courses on administering medication. ADON said RN A will be monitored for 10 weeks and random observations of medication passes will be completed each week to ensure RN A's proficiency. ADON said she is responsible for monitoring RN A's proficiency in administering medciations and had started observing medication passes today. ADON said quality assurance (QA) meetings are held monthly. ADON said all medication errors are discussed monthly at the QA meeting. Employee training records showed RN A received in-service training on 03/17/21 on the rights of administering medication. RN A completed online courses on Medication Administration for older adults on 03/19/21. Inservice records showed on 03/17/21 nursing staff and medication aids received training on 5 rights of medication administration. During interviews with MA A, LVN B, LVN C and RN B on 03/19/21 at 12:10 p.m., 12:17 p.m., 12:23 p.m. and 12: 35 p.m. said they received in-service training on 03/17/21 on administering medication. They were able to identify the five rights of administering medication as right person, medication, route, time and dose.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for 6 of 12 residents reviewed for neglect. (Resident #'s 201, 48, 16, 33, 49, 102) The facility did not provide sufficient staff to complete weekly skin assessments and turn and reposition Resident #201 to promote the healing and prevent worsening of a stage 3 pressure injury on her sacrum. The facility did not provide staff with appropriate competencies to provide wound care to promote healing and prevent infections of Resident #48's stage 4 pressure injury and provide sufficient staff to turn and reposition the resident to prevent development of a new pressure injury. The facility did not provide sufficient staff to turn and reposition Resident #16 to promote the healing and the worsening of a stage 3 pressure injury to the sacrum. The facility did not provide sufficient staff to turn and reposition Resident #33 to prevent the development of two new pressure injuries to her left elbow and left knee and provide staff with knowledge of the correct settings for the Resident 33's low air loss mattress. The facility did not provide sufficient staff with appropriate competencies to regularly assess Resident #49's skin regularly, identify new pressure injuries, recognize significant weight loss and turn and reposition the resident. The facility failed to provide staff with appropriate competencies to ensure Resident #102's blood sugars were appropriately monitored. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 5:20 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could place residents at risk of not receiving care and services to meet their needs, illness and death. Findings included: The facility assessment updated [DATE] indicated overall the resident population required assistance with ADLs as follows: *Dressing - 42 residents assist of ,[DATE] staff; 6 residents are dependent upon staff. *Bathing - 42 residents require assist of ,[DATE] staff; 17 residents are dependent upon staff. *Transfer - 41 residents require assist of ,[DATE] staff; 6 residents are dependent upon staff. *Eating - 48 residents require assist of ,[DATE] staff; 1 resident is dependent upon staff. *Toileting - 35 residents require assist of ,[DATE] staff; 14 residents are dependent upon staff. The facility assessment updated [DATE] indicated the general staffing plan to ensure sufficient staff members to meet the needs of residents at any given time was as follows: *RN or LPN charge nurse: 3 for each shift *1:17 licensed nurse ratio days and evenings *1:26 licensed nurse nights *Direct care staff members: 1:5 ratio days; 1:8 ratio evenings; 1:10 ratio nights. 1. A face sheet dated [DATE] indicated Resident #201 was [AGE] years old and admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated Resident #201 was discharged from the facility on [DATE] for surgical debridement of her sacral pressure injury. Hospital records dated [DATE] indicated Resident #201 was being treated at a behavioral hospital and fell then admitted to the hospital for a [MEDICAL CONDITION] and the hip was repaired on [DATE]. The records indicated Resident #201 did not have any pressure injuries and there was not a [DIAGNOSES REDACTED]. Physician orders [REDACTED].#201 had wound care orders for the sacral pressure injury to cleanse with normal saline, apply Santyl to wound and cover with dry dressing every day, low air loss mattress, pressure reduction device to bed and or chair, reposition Resident #201 every two hours and as needed and avoid pressure to sacrum. A significant change MDS dated [DATE] indicated Resident #201 had clear speech, was able to understand others and could make herself understood. Resident #201 had moderate cognitive impairment and was incontinent of bowel and bladder. Resident #201 had verbal behaviors directed towards others and would intrude on the privacy or activity of others and would significantly disrupt care or living environment. The MDS indicated Resident #201 required extensive assistance of two staff members for bed mobility. The MDS indicated the resident required extensive assistance of one staff member for dressing, limited assistance for eating and was dependent on staff for personal hygiene. The MDS indicated Resident #201 was at risk for developing pressure injuries and had one unhealed pressure injury, stage 3 upon admission. A care plan dated [DATE] indicated staff would assist Resident #201 with turning and repositioning as needed while in bed. The care plan indicated staff would shower Resident #201 three times per week and as needed. The care plan indicated a low-air loss mattress was placed on her bed on [DATE]. The care plan indicated staff would assess Resident #201's skin weekly per the facility policy. The care plan indicated staff would off-load her heels and would turn and reposition Resident #201 as needed and with each incontinent episode. The care plan indicated staff would position Resident #201 with pillows to elevate pressure points off the bed. The care plan updated on [DATE] indicated Resident #201 had a sacral wound, and she did not have a catheter. The initial wound care specialist evaluation dated [DATE] indicated Resident #201 had a stage 3 sacral wound that measured 3 cm length, 5 cm in width, and 0.2 cm in depth. The description included light serous drainage and 100% slough. The wound care orders were for Santyl once a day with a foam border dressing. A nursing note dated [DATE] indicated Resident #201 yelled out as usual with all care provided. A nursing note dated [DATE] indicated Resident #201 continued to scream she was hurting, and the physician was notified. The nursing note indicated yelling could be a behavioral episode and the physician referred Resident #201 to behavioral care and to inform the behavioral physician. A nursing note dated [DATE] indicated Resident #201 yelled out and was screaming because she wanted to get out of bed. The note did not indicate if Resident #201 was gotten out of bed. A notification of change in condition, dated [DATE], indicated the facility notified the physician Resident #201's pain was not managed related to Resident #201 yelling and crying out during the entire shift, after pain medications were given. The note indicated the physician said he was told the day before the resident was ok. The physician increased the resident's [MEDICATION NAME] to 2 tablets every 6 hours, as needed for pain. A nursing note dated [DATE] indicated Resident #201 yelled and complained of buttocks pain, and Resident #201's cognitive status did not allow her to verbalize understanding of repositioning, and the risk of worsening pressure injury. A nursing note dated [DATE] indicated Resident #201 yelled out and complained of buttocks pain. The note indicated medication and repositioning were effective and Resident #201 continued to yell out when care was provided. A nursing note dated [DATE] indicated Resident #201 shouted at staff to get her up or yelled for her husband to come get her. The note did not indicate if staff assisted Resident #201 to get up. A notification of change in condition dated [DATE] sent to the physician indicated Resident #201 continued to scream out for most of the time she was awake. The note indicated the current medications were [MEDICATION NAME] 7.5 mg every 6 hours as needed for pain, [MEDICATION NAME] 100 mg every 6 hours as needed for pain, and [MEDICATION NAME] 25 mg twice a day. The communication indicated the nurse believed pain was present although Resident #201 denied pain and yelled to be gotten up. The communication did not indicate Resident #201 was assisted to get up. A notification of change in condition dated [DATE] sent to indicated Resident #201 had a large amount of purulent, thick, brown, foul smelling drainage and area surrounding wound was red and warm on her sacral pressure injury. The physician responded, why was I not notified when I was in the facility this morning, something like this needs surgery. A nursing note dated [DATE] indicated Resident #201's physician was notified of the wound condition and changed wound care orders to include; apply Santyl, pack loosely with packing strip and cover with dry dressing and obtain a wound culture. Physician orders [REDACTED].#201's sacral wound to be cleansed with wound cleanser, apply [MEDICATION NAME], and fill wound bed loosely with packing and cover twice per day. A notification of change of condition sent to the physician dated [DATE] indicated Resident #201's stage 3 wound to her sacrum was scheduled for debridement and a urinary catheter was inserted. A wound culture report dated [DATE] indicated Resident #201 had proteus mirabilis and Escherichia coli (bacteria found in the digestive tract) in her wound. A notification of change of condition sent to the physician dated [DATE] indicated Resident #201 was admitted to the hospital for sharp debridement of the sacral wound. A hospitalist progress note dated [DATE] indicated Resident #201 was admitted to the hospital on [DATE] for clearance for outpatient surgical debridement of sacral ulcer. The note indicated the resident presented on a stretcher screaming in pain and was severely demented. The note indicated she was frail and cachectic (general ill health with emaciation), was in distress and had a smell of necrotic (death of tissue) flesh with purulent (containing pus) exudate (a fluid) oozing from her sacrum. The noted indicated Resident #201 had a stage 4 sacral ulcer to the bone with bubbles and exudate that was spontaneously dripping all over the hospital bed. The assessment and plan in the note indicated Resident #1 [MEDICAL CONDITION], a stage 4 sacral pressure injury with gas gangrene, [MEDICAL CONDITION](high heart rate), severe dementia, debility with contractures, acute kidney injury, stage ,[DATE] [MEDICAL CONDITION], and severe protein calorie malnutrition. An inpatient discharge summary dated [DATE] indicated Resident #201 came in [MEDICAL CONDITION] due to gas gangrene of her sacrum with sacral ulcer. The summary indicated she was found to have poor quality of life and very poor chances of healing or improving, and her family opted for inpatient hospice. The summary indicated Resident #201 expired at 6:38 a.m. on [DATE]. During an interview on [DATE] at 9:39 a.m., the complainant said that Resident #201 was admitted to a hospital for debridement of a sacral pressure injury that tested positive for a bacterial infection. She said the wound was open, draining foul, brown, exudate and her bone was exposed. The complainant said Resident #201 was admitted to the hospital for severe dehydration and gangrene (death of body tissue due to either lack of blood flow or a serious bacterial infection) to her wound. She said the hospitalist told her that Resident #201 would probably not recover. She was placed on hospice at the hospital and passed away on [DATE]. During an interview on [DATE] at 2:51 p.m., RN L said Resident #201 did not understand to stay repositioned or offloaded to her side. He said he was able to reposition Resident #201 when she was asleep. He said when she was awake she was constantly moving, and she would wiggle back onto her back, he said he thought it was because of pain. He said if Resident #201 resisted ADLs or wound care, he would re-approach and attempt later. He said he always managed to get her wound care done. During an interview on [DATE] at 9:45 a.m., CNA F said she had worked here approximately 5 months. She said it was herself and another aide for all 3 halls with approximately 36 residents between the 2 of them. She said she knew residents were supposed to be turned every 2 hours, but the aides were unable to routinely do this. She said they could not keep up with resident care. During an interview on [DATE] at 10:20 a.m., CNA F said it was very hard to keep all the residents repositioned every 2 hours. She said staff tried to get it all done but that there were many dependent residents. CNA F said aides must prioritize the call lights because there aren't enough aides to answer the lights promptly. CNA F said she hated to make a resident sit in a soiled brief after an incontinent episode because she was busy cleaning up a resident who vomited. CNA F said the facility needed more staff to prevent skin breakdown and pressure injuries. During an interview on [DATE] at 2:04 p.m., RN A said aides were responsible for repositioning dependent residents. She said she had not monitored them to ensure they were doing it because she as very overwhelmed with other resident care since she was the only nurse on the floor. RN A said the facility did not have enough staff to effectively care for the residents. During an interview on [DATE] at 2:00 p.m., MA L said that Resident #201 was very vocal, and yelled out all the time. She said Resident #201 would not refuse care including turning and repositioning, she said she would sometimes try to resist care, but staff could usually talk her into letting them provide incontinent care and reposition her. During an interview on [DATE] at 4:32 p.m., LVN P said that Resident #201 would sometimes resist ADL care but after reattempting and encouragement, she would allow care. He said she would yell out a lot and staff would reposition her, but she always rolled back onto her back. During an interview on [DATE] at 3:21 p.m., the ADON said Resident #201 did not like to be touched. She said staff would get her up at times, and she said they tried their best with repositioning her as she would refuse to be turned. During an interview on [DATE] at 3:30 p.m., the administrator said he expected staff to reposition residents at risk for pressure injuries. 2. Consolidated physician orders [REDACTED].#48 was [AGE] years old, admitted on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. saline, apply hypochlorite, apply collagen powder and loosely pack the wound with [MEDICATION NAME] gauze, and cover with a dry dressing daily. The most recent MDS dated [DATE] indicated Resident #48 had clear comprehension, made herself understood, and was cognitively intact. The MDS indicated Resident #48 required total assistance with bed mobility, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #48 was at risk for developing pressure injuries. The MDS indicated Resident #48 had one stage 4 pressure injury present on admission. A care plan updated on [DATE] indicated Resident #48 was at risk for developing pressure injuries and had a stage 4 pressure injury on her sacrum. The care plan indicated Resident #48's pressure injury would show signs of healing and would remain free from infection. The care plan indicated the following interventions would be provided for Resident #48: *position with pillows to elevate pressure points off bed; *a skin inspection was completed every shift during routine care; *turn and reposition every 2 hours and as needed; *cleanse pressure injury with saline, apply hypochlorite gel, apply collagen powder, loosely pack the wound bed with [MEDICATION NAME] gauze and cover with dry dressing daily; *assess/record/monitor wound healing at least weekly and report decline to physician; and *avoid positioning resident on her back. A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx measuring 2.2 cm x 1.3 cm x 0.8 cm with undermining measuring 4.3 cm at 12 o'clock. The summary indicated the wound had light serous exudate with 10 % slough and 90% granulation. The summary indicated the wound had improved. The summary indicated there was a surgical excisional debridement. A nursing note dated [DATE] at 4:55 p.m. indicated Resident #48 had an open area, with the top layer of skin missing at the base of her left dorsal thumb. The nurse's note did not indicate a new treatment was ordered for the new wound and did not describe or stage the area. The note indicated Resident #48's primary care physician was notified by fax. During an observation on [DATE] at 2:06 p.m., Resident #48 was lying in bed with her eyes closed, positioned on her right side, and a foul odor was noted. Resident #48's hands were crossed with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 3:33 p.m., Resident #48 was lying in bed, with her eyes closed, positioned on her right side, and had a moderate foul odor. Resident #48's hands were crossed with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 10:35 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted in her room. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 11:20 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted near her in her room. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left thumb. During an observation on [DATE] at 11:58 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 2:45 p.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an interview on [DATE] at 3:09 p.m., RN A said there was not enough staff to keep all the residents clean and dry and turned and repositioned every 2 hours. RN A said she had not worked in long term care in a very long time and did not have much training before having to work as the charge and wound treatment nurse. RN A said she was trained on the medication cart her first day, helped the other nurse gather vital signs the second day, and passed medication the third day of training. RN A said after the third day she was placed as the charge nurse and had to figure it all out. RN A said she felt she was constantly putting out fires, instead of being proactive because she did not have enough time. RN A said she was responsible for completing her residents' skin assessments and wound care treatments. During an observation and interview on [DATE] at 3:18 p.m., Resident #48 was lying in bed on her back and a foul odor was noted. Resident #48's hands were crossed across her stomach, with the edge of her right hand positioned on top of the base of her left dorsal thumb. Resident #48's left hand at the base of her thumb had a clear dressing over a wound measuring approximately 2 cm in length and 2 cm in width. The wound had yellow drainage covering the wound bed. The surrounding tissue was bright red. RN A said she discovered an open blister on the area on [DATE]. RN A said she did not know the facility's policy on staging wounds and did not stage the area. RN A said Resident #48 kept her hands together most of the time which contributed to the area being open. Resident #48 was positioned on her right side and a strong, foul, odor was noted. RN A removed Resident #48's old dressing from the Stage 4 pressure injury on the resident's sacrum, and a very strong, foul odor engulfed the room. The old dressing was saturated with brown drainage, and large amounts of yellow and brown drainage was on Resident #48's brief. RN A said the yellow and brown drainage on Resident #48's brief was wound drainage. RN A cleaned the wound with normal saline and measured the wound as 2.5 cm in length, 2 cm in width, 0.8 cm in depth, and undermining 3 cm at 12 o'clock. The wound bed that was visible was pink and red, the undermining wound bed was unable to be visualized. While RN A measured the wound, white packing fell out of the wound edge to the wound opening. RN A gathered new packing strips and collagen mixture and proceeded to pack the wound without removing the old packing. When asked what the substance was in the wound, RN A said it was the old packing. She removed the old packing, cleaned the wound with normal saline, and placed new packing and collagen mixture in a ball shape on the wound surface. RN A did not pack the undermining or all the wound bed. The pressure injury was covered with a dry dressing. During wound care, RN A did not wash or sanitize her hands between glove changes. During an interview on [DATE] at 3:35 p.m., CNA B said there were not enough staff to keep the residents turned and repositioned every 2 hours. During an observation on [DATE] at 10:05 a.m., Resident #48 was lying in bed on her right side, her hands were together with her right hand on top of left hand at the base of her thumb at the pressure injury site. During an interview on [DATE] at 10:15 a.m., the ADON said the charge nurses were responsible for completing skin assessments and performing their own pressure injury treatments. The ADON said the charge nurses had no formal pressure injury training. The ADON said the residents had an order that indicated when their skin assessments were due. The ADON said she did not know why there were missing skin assessments and the DON was responsible for monitoring the skin assessments were completed. The ADON said the nurses were supposed to notify the residents' physician immediately when a new or changed pressure injury was identified. During an interview on [DATE] at 10:13 a.m., CNA C said residents were supposed to be turned and repositioned at least every 2 hours. CNA C said they were not able to turn and reposition residents every 2 hours because there were not enough staff. CNA C said Resident #48 had pressure injuries and needed to be turned every 2 hours. CNA C said she was employed at the facility's sister facility and was in working in this facility to help them out because they did not have enough staff. During an interview on [DATE] at 10:18 a.m., LVN D said residents were supposed to be turned and repositioned at least every 2 hours. LVN D said she was helping in the facility today but normally worked in a sister facility. During an interview on [DATE] at 10:21 a.m., CNA [NAME] said Resident #48 should not be positioned on her back and should have a pillow between her hands. CNA [NAME] said residents were supposed to be turned and repositioned at least every 2 hours but were unable to because there were not enough staff. During an interview on [DATE] at 11:14 a.m., CNA F said residents should be turned and repositioned at least every 2 hours, but they were not able to because there were not enough staff. During an observation and interview on [DATE] at 11:25 a.m., Resident #48 was lying on her right side and her right hand was positioned on the base of her left-hand thumb at the pressure injury site. Resident #48 had a rag in her right hand that was resting on her left wrist and caused a blanchable red area. RN A said Resident #48 should be turned and repositioned every 2 hours but had not been because there was not enough staff to keep everyone turned. RN A said Resident #48 should not be positioned on her back. RN A said Resident #48 should have a pillow between her hands to prevent pressure injuries. RN A said the new area on the base of Resident #48's left thumb was a stage 2. RN A said the odor from Resident #48's stage 4 pressure injury on her coccyx during the treatment change on [DATE] was necrotic tissue and possibly infection. RN A said during the treatment change on [DATE] she almost left the old packing in the wound because she thought the wound had one strip of packing instead of two. RN A said she did not wash or sanitize her hands between changing gloves during Resident #48's pressure injury dressing change. RN A said she should have washed her hands between changing her gloves. During an interview on [DATE] at 1:46 p.m., the ADON said she knew there was a staffing problem and had been working as a charge nurse frequently. During an interview on [DATE] at 3:58 p.m., the administrator said he expected adequate staff to be scheduled, residents to be turned at least every 2 hours, appropriate pressure injury treatments to be in place, and the physician to be notified of changes in pressure injuries. 3. Consolidated physician orders [REDACTED].#16 was [AGE] years old, and admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].#16 had weekly skin assessments every Wednesday on the night shift. The physician orders [REDACTED].#16's weekly skin assessments would be every Friday on the day shift. The physician orders [REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #16 sometimes understood others, sometimes made herself understood, and had severe cognitive impairment. The MDS indicated Resident #16 required extensive assistance with eating, and total assistance with bed mobility, transferring, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident #16 was at risk for developing pressure injuries and had one existing stage 2 pressure injury not present on admission. A care plan dated [DATE] indicated Resident #16 was at risk for pressure injuries due to decreased mobility, chair fast, and incontinence. The care plan indicated Resident #16's skin would remain intact without evidence of redness, irritation, maceration, or open areas. The care plan did not address turning and repositioning. A care plan dated [DATE] indicated Resident #16 had a stage 3 pressure injury on her sacrum. The care plan indicated Resident #16's pressure injury would not exhibit signs of infection, had dressing changes as ordered by the physician and indicated Resident #16 had weekly skin assessments and to report signs of further skin breakdown. The care plan did not address turning and repositioning. A wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #16 had a stage 3 pressure injury on her sacrum measuring 1.6 x 1 x 0.1 cm with light serous exudate. The evaluation indicated 20% slough and 80% granulation tissue. The note indicated the wound had deteriorated During an observation and interview on [DATE] at 11:35 a.m., Resident #16's stage 3 pressure injury measured 3.8 cm in length, 2.5 cm in width, and approximately 0.2 cm in depth. The wound bed was pink with a small amount of slough, no odor. The wound edges were black eschar (dead tissue). RN A said Resident #16's pressure injury had worsened since [DATE]. RN A said Resident #16's wound edges did not have eschar and the wound bed did not have slough on [DATE]. RN A said the pressure injury was unstageable. During an interview on [DATE] at 2:01 p.m., Resident #16's wound care nurse practitioner (NP) said he had not been notified of changes in Resident #16's sacrum pressure injury. The NP said he saw Resident #16's sacrum pressure injury on [DATE] and there was no necrotic tissue or eschar surrounding the wound. The NP said he should have been notified of the changes immediately. During an interview on [DATE] at 1:46 p.m., the ADON said she expected Resident #16's physician and/or wound care nurse practitioner to be notified of changes or worsening of her pressure injury. The ADON said she expected Resident #16's skin to be consistently assessed weekly. During an interview on [DATE] at 3:58 p.m., the administrator said he expected residents to be turned at least every 2 hours, appropriate pressure injury treatments to be in place, and the physician to be notified of changes in pressure injuries. 4. A face sheet, dated [DATE] indicated Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #33 was understood and understand others and had a BIMS score of 5 indicating severe cognitive impairment. The MDS indicated she required extensive assistance with two-person physical assist for bed mobility, transfers, toilet use and personal hygiene. The MDS indicated Resident #33 was always incontinent of bladder and bowel and was at risk of pressure ulcers. A care plan dated [DATE] indicated Resident #33 was at risk for pressure ulcers. Interventions included skin inspection every shift during routine ADL care, she would be turned every 2 hours, a low air loss mattress and keep resident off bony prominences as she would allow. An initial wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #33 had an unstageable sacrum wound measuring 3 x 3.6 x 0.3 cm with light serous exudate. The summary indicated the wound had 100% adherent devitalized necrotic tissue and surgical excisional debridement was completed. A wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #33 had an unstageable wound to her sacrum measuring 4 x 2.5 x 0.4 cm with moderate serous exudate. The evaluation indicated the wound had 100% thick adherent devitalized necrotic tissue and the wound had improved. The evaluation indicated a surgical excisional debridement was completed. The evaluation indicated Resident #33 had a DTI to her right heel measuring 4 cm x 8 cm. During an observation on [DATE] at 11:35 a.m. Resident #33 was lying in bed on her left side. The low air loss mattress pump was set to 9, the firmest setting. During an observation on [DATE] at 2:00 p.m., Resident #33 was lying in bed on her left side. The low air loss mattress was set at 9. During an observation on [DATE] at 10:55 a.m., Resident #33 was lying in bed on her left side. The low air loss mattress was set at 9. During an observation on [DATE] at 2:19 p.m., Resident #33 was lying on her left side and the low air loss pump was set on 9. During an observation on [DATE] at 2:45 p.m., RN A performed routine wound care and a skin assessment for Resident #33. RN A identified a pressure injury to Resident #33's left elbow measuring 1.8 cm in length x 1.8 cm in width, and a pressure injury on Resident #33's left knee measuring 3.5 cm x 3 cm x and 0.1 cm. During an observation on [DATE] at 10:05 a.m., Resident #33 was lying in bed on her left side. The low air loss mattress was set at 9. During an observatio (TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 5 of 5 residents reviewed for pressure injuries. (Resident #s 201, 48, 16, 33, and 49) The facility did not complete weekly skin assessments for Resident #201 as ordered by the physician and did not notify the physician when the resident developed a DTI on her left heel. The facility did not provide interventions when Resident #201's stage 3 pressure injury to the sacrum worsened and developed infection. The wound had signs and symptoms of infection for 17 days before the facility sent Resident #201 to the hospital where she was diagnosed with [REDACTED]. The resident was admitted to inpatient hospice and died in the hospital. The facility did not implement interventions to promote healing and prevent infection of a stage 4 pressure injury to the sacrum of Resident #48 and prevent the development of a new stage 2 pressure injury to her left thumb. The facility did not position the resident off her back, stage and receive orders for treatment of [REDACTED]. The facility did not implement interventions to prevent the development of two new pressure injuries to Resident #33's left elbow and left knee. The facility did not reposition the resident and keep her off bony prominences as indicated by her care plan. The staff did not know the correct settings for Resident #33's low air loss mattress according to her weight. The facility did not assess Resident #49's skin regularly, identify new pressure injuries and implement interventions to prevent pressure injury development as care planned. CNA [NAME] did not report an open area on Resident #49's bottom to the nurse and did not apply barrier cream after an incontinent episode. The facility did not address interventions in Resident #16's care plan to promote the healing and prevent worsening of a stage 3 pressure injury to her sacrum. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 5:20 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could place residents who were at risk for pressure injuries and had pressure injuries at risk for development or worsening of existing pressure injuries, wound infections and death. Findings included: 1. A face sheet in a closed record for Resident #201 dated [DATE] indicated she was [AGE] years old and admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated Resident #201 was discharged from the facility on [DATE] for surgical debridement of her sacral pressure injury. Hospital medical records dated [DATE] indicated Resident #201 was being treated at a behavioral hospital and fell then admitted to the hospital for a [MEDICAL CONDITION] and the hip was repaired on [DATE]. The records indicated Resident #201 did not have any pressure injuries and there was not a [DIAGNOSES REDACTED]. A readmission skin assessment dated [DATE] indicated Resident #201 had a surgical wound with 19 staples to her left hip, and a bruise to her left hand. No other skin issues were documented A Braden scale for predicting pressure injury risk dated [DATE] indicated Resident #201 was at moderate risk for developing pressure injuries. Physician orders dated [DATE] indicated Resident #201 had wound care orders for the sacral pressure injury to cleanse with normal saline, apply Santyl to wound and cover with dry dressing every day, low air loss mattress, pressure reduction device to bed and or chair, reposition Resident #201 every two hours and as needed and avoid pressure to sacrum, skin assessments to be done weekly, nutritional interventions of multivitamin, vitamin C and fortified milk with all meals. A significant change MDS dated [DATE] indicated Resident #201 had clear speech, was able to understand others and could make herself understood. Resident #201 had moderate cognitive impairment and was incontinent of bowel and bladder. Resident #201 had verbal behaviors directed towards others and would intrude on the privacy or activity of others and would significantly disrupt care or living environment. The MDS indicated Resident #201 required extensive assistance of two staff members for bed mobility and was not transferred out of bed during this seven day look back. The MDS indicated the resident was not placed in a wheelchair or moved from her room and required extensive assistance of one staff member for dressing, limited assistance for eating and was dependent on staff for personal hygiene. The MDS indicated Resident #201 did not receive a full body bath or shower during this 7 day look back. The MDS indicated Resident #201 was at risk for developing pressure injuries and had one unhealed pressure injury, stage 3 upon admission. The MDS indicated Resident #201 received an antipsychotic for two of seven days, an anti-anxiety four of seven days, and an opioid for four of seven days of the look back period. The MDS indicated Resident #201 did not have a behavior of refusing care. A nursing note dated [DATE] indicated Resident #201 had a purple colored area to the sacrum measuring 6 cm (centimeters) in length and 2.3 cm in width. The note indicated Resident #201 cried out and said her hip and butt hurt. A notification of change of condition dated [DATE] sent to the physician indicated Resident #201 had an unstageable pressure injury to her sacrum that required; turning and repositioning every 2 hours left to right to avoid pressure to sacrum, and moisture barrier with each incontinent episode. A nursing note dated [DATE] indicated Resident #201 had an open wound to her sacrum with a white wound bed and black in color. The note indicated Resident #201 was placed on a low air loss mattress. The note did not indicate a setting for the mattress did not indicate the primary care physician was notified of the wound. The initial wound care specialist evaluation dated [DATE] indicated Resident #201 had a stage 3 sacral wound that measured 3 cm length, 5 cm in width, and 0.2 cm in depth. The description included light serous drainage and 100% slough. The wound care orders were for Santyl once a day with a foam border dressing. A nursing note dated [DATE] indicated Resident #201 yelled out as usual with all care provided. Resident #201's wound was described to have eschar present with no drainage. A nursing note dated [DATE] indicated Resident #201 continued to scream she was hurting, and the physician was notified. The nursing note indicated yelling could be a behavioral episode and the physician referred Resident #201 to behavioral care and to inform the behavioral physician. A nursing note dated [DATE] indicated Resident #201 yelled out and was screaming because she wanted to get out of bed. The note did not indicate if Resident #201 was gotten out of bed. A weekly skin assessment dated [DATE] was blank. A notification of change in condition, dated [DATE], indicated the facility notified the physician Resident #201's pain was not managed related to Resident #201 yelling and crying out during the entire shift, after pain medications were given. The note indicated the physician said he was told the day before the resident was ok. The physician increased the resident's [MEDICATION NAME] to 2 tablets every 6 hours, as needed for pain. A nursing note dated [DATE] indicated Resident #201 yelled and complained of buttocks pain, and Resident #201's cognitive status did not allow her to verbalize understanding of repositioning, and the risk of worsening pressure injury. A nursing note dated [DATE] indicated Resident #201 yelled out and complained of buttocks pain. The note indicated medication and repositioning were effective and Resident #201 continued to yell out when care was provided. A wound care specialist evaluation dated [DATE] indicated Resident #201 had a stage 3 sacral wound measuring 2.5 cm in length, 2.5 cm in width, and 0.7 cm in depth. The description included light serous drainage and 100% slough. The wound care orders were Santyl once a day with foam border dressing. A nursing note dated [DATE] indicated Resident #201's wound was covered in slough and had a very foul odor (sign of infection). The note did not indicate the physician was notified. There was not a weekly skin assessment completed for the week of [DATE]. A nursing note dated [DATE] indicated Resident #201's low air loss mattress malfunctioned and deflated. The note indicated staff transferred Resident #201 to a regular mattress. A nursing note dated [DATE] indicated Resident #201 shouted at staff to get her up or yelled for her husband to come get her. The note did not indicate if staff assisted Resident #201 to get up. A notification of change in condition dated [DATE] sent to the physician indicated Resident #201 continued to scream out for most of the time she was awake. The note indicated the current medications were [MEDICATION NAME] 7.5 mg every 6 hours as needed for pain, [MEDICATION NAME] 100 mg every 6 hours as needed for pain, and [MEDICATION NAME] 25 mg twice a day. The communication indicated the nurse believed pain was present although Resident #201 denied pain and yelled to be gotten up. The communication did not indicate Resident #201 was assisted to get up. The wound care specialist evaluation dated [DATE] indicated Resident #201 had a stage 3 sacral wound measuring 3.3 cm in length, by 2 cm in width, and 1 cm in depth. The description included light serous drainage and 100% slough. The wound care orders indicated Santyl once a day with foam border dressing. The wound care specialist did not indicate an odor. A nursing note dated [DATE] indicated Resident #201's pressure injury was worsening, the surrounding tissue was dark red to purple, with a very foul odor and purulent drainage. The note did not indicate the physician or wound care specialist was notified. A Braden scale for predicting pressure injury risk dated [DATE] indicated Resident #201 was at moderate risk for developing pressure injuries. The wound care specialist evaluation dated [DATE] indicated Resident #201 had a stage 3 sacral wound measuring 3.2 cm in length, 3 cm in width, and 1 cm in depth. The evaluation indicated the wound had light serous drainage and 100% slough. The treatment ordered was Santyl once per day with foam dressing. The evaluation indicated the specialist assessed Resident #201's feet and did not indicate a pressure injury to Resident #201's left heel. A weekly skin assessment dated [DATE], on the evening shift, indicated Resident #201 had a fluid filled blister on her left heel measuring 3.5 cm (centimeters) in length by 3.7 cm in width; and a pressure injury to Resident #201's sacrum that measured 3 cm in length, by 2.5 cm width and 1.5 cm with undermining at 10 o'clock of 2.2 and undermining at 12 o'clock of 2.3 cm. The wound was described as having necrotic tissue (eschar)-black, brown, or tan tissue; a moderate amount of exudate, purulent in color and had a foul odor. The assessment did not indicate the physician or wound care specialist was notified of the left heel pressure injury. The assessment did not indicate a treatment order was received for the wound on Resident #201's heel. A notification of change in condition dated [DATE] sent to the physician indicated Resident #201 had a large amount of purulent, thick, brown, foul smelling drainage and area surrounding wound was red and warm on her sacral pressure injury. The physician responded, why was I not notified when I was in the facility this morning, something like this needs surgery. A nursing note dated [DATE] indicated Resident #201's physician was notified of the wound condition and changed wound care orders to include; apply Santyl, pack loosely with packing strip and cover with dry dressing and obtain a wound culture. A care plan dated [DATE] indicated staff would assist Resident #201 with turning and repositioning as needed while in bed. The care plan indicated staff would shower Resident #201 three times per week and as needed. The care plan indicated a low-air loss mattress was placed on her bed on [DATE]. The care plan indicated staff would assess Resident #201's skin weekly per the facility policy. The care plan indicated staff would off-load her heels and would turn and reposition Resident #201 as needed and with each incontinent episode. The care plan indicated staff would position Resident #201 with pillows to elevate pressure points off the bed. The care plan updated on [DATE] indicated Resident #201 had a sacral wound. Physician orders dated [DATE] indicated order for Resident #201's sacral wound to be cleansed with wound cleanser, apply [MEDICATION NAME], and fill wound bed loosely with packing and cover twice per day. A notification of change of condition sent to the physician dated [DATE] indicated Resident #201's stage 3 wound to her sacrum was scheduled for debridement and a urinary catheter was inserted. A wound culture report dated [DATE] indicated Resident #201 had proteus mirabilis (bacteria found in urine) and Escherichia coli (bacteria found in the digestive tract) in her wound. A notification of change of condition sent to the physician dated [DATE] indicated Resident #201 was admitted to the hospital for sharp debridement of the sacral wound. A hospitalist progress note dated [DATE] indicated Resident #201 was admitted to the hospital on [DATE] for clearance for outpatient surgical debridement of sacral ulcer. The note indicated the resident presented on a stretcher screaming in pain and was severely demented. The note indicated she was frail and cachectic (general ill health with emaciation), was in distress and had a smell of necrotic (death of tissue) flesh with purulent (containing pus) exudate (a fluid) oozing from her sacrum. The noted indicated Resident #201 had a stage 4 sacral ulcer to the bone with bubbles and exudate that was spontaneously dripping all over the hospital bed. The assessment and plan in the note indicated Resident #1 [MEDICAL CONDITION], a stage 4 sacral pressure injury with gas gangrene (death of body tissue due to either lack of blood flow or a serious bacterial infection), [MEDICAL CONDITION](high heart rate), severe dementia, debility with contractures, acute kidney injury, stage ,[DATE] [MEDICAL CONDITION], and severe protein calorie malnutrition. A physician progress notes [REDACTED].#201 to inpatient hospice care with comfort measures only. A hospitalist progress note dated [DATE] indicated Resident #201 was admitted to inpatient hospice the previous night and continued to have crying spells with pain. The note indicated the resident [MEDICAL CONDITION], a sacral pressure injury, [MEDICAL CONDITION](high heart rate) stage 4 with gas gangrene, severe dementia, debility with contractures, acute kidney injury, stage ,[DATE] [MEDICAL CONDITION], severe protein calorie malnutrition and intractable (hard to control) sacrum pain. A hospitalist progress note dated [DATE] indicated Resident #201 was admitted with a stage 4 sacral ulcer [MEDICAL CONDITION] and gas gangrene and was terminal. The note indicated the resident's pain was difficult to control without IV narcotics and pain was worse with any manipulation or movement. An inpatient discharge summary dated [DATE] indicated Resident #201 came in [MEDICAL CONDITION] due to gas gangrene of her sacrum with sacral ulcer. The summary indicated she was found to have poor quality of life and very poor chances of healing or improving, and her family opted for inpatient hospice. The summary indicated Resident #201 expired at 6:38 a.m. on [DATE]. During an interview on [DATE] at 9:39 a.m., the complainant said that Resident #201 was admitted to a hospital for debridement of a sacral pressure injury that tested positive for a bacterial infection. She said the wound was open, draining foul, brown, exudate and her bone was exposed. The complainant said Resident #201 was admitted to the hospital for severe dehydration and gangrene of her wound. She said the hospitalist told her Resident #201 would probably not recover. She was placed on hospice at the hospital and passed away on [DATE]. During an interview on [DATE] at 2:51 p.m., RN L said he discovered Resident #201 had a DTI a few days after re-admission following hip surgery which occurred on [DATE]. He said he documented the initial assessment of the wound on a notification to the physician form. He said the wound did not change in severity at first, then it began to worsen. He said she was not eating well, and it was difficult to heal because the resident was non-compliant with repositioning related to her dementia. RN L said Resident #201 did not understand to stay repositioned or offloaded to her side. He said he was able to reposition Resident #201 when she was asleep. He said when she was awake she was constantly moving, and she would wiggle back onto her back. He said he thought she moved so much was because of pain. He said if Resident #201 resisted ADLs or wound care, he would re-approach and attempt later. He said he always managed to get her wound care done. During an interview on [DATE] at 11:25 a.m., RN M said Resident #201 was on the unit and would yell loudly. He said she was sent to a behavioral hospital for behaviors and during her stay there, she suffered a [MEDICAL CONDITION]. He said she admitted back to this facility onto the regular floor and he did not take care of her after her return. RN M said Resident #201 did not have any wounds prior to being sent the hospital. During an interview on [DATE] at 9:45 a.m.,CNA F said she had worked at the facility for approximately 5 months. She said it was herself and another aide for all 3 halls with approximately 36 residents. She said she knew residents were supposed to be turned every 2 hours but the aides were unable to routinely do this. She said they could not keep up with resident care. During an interview on [DATE] at 10:20 a.m., CNA F said it was very hard to keep all the residents repositioned every 2 hours. She said staff tried to get it all done but that there were many dependent residents. CNA F said aides must prioritize the call lights because there aren't enough aides to answer the lights promptly. CNA F said she hated to make a resident sit in a soiled brief after an incontinent episode because she was busy cleaning up a resident who vomited. CNA F said the facility needed more staff to prevent skin breakdown and pressure injuries. During an interview on [DATE] at 2:04 p.m., RN A said aides were responsible for repositioning dependent residents. She said she had not monitored them to ensure they were doing it because she was overwhelmed with other resident care since she was the only nurse on the floor. RN A said the facility did not have enough staff to effectively care for the residents. During an interview on [DATE] at 2:00 p.m., MA L said that Resident #201 was very vocal, and yelled out all the time. MA L said after Resident #201 came back from the behavioral hospital, she was on the main hall and yelled continually. MA L said some residents complained about Resident #201's yelling. The main hallway was very busy all the time, and Resident #201 was moved to the private hall to decrease stimuli. She said Resident #201 would not refuse care including turning and repositioning, she said she would sometimes try to resist care, but staff could usually talk her into letting them provide incontinent care and reposition her. During an interview on [DATE] at 2:05 p.m., MA G said that Resident #201 would yell and holler out a lot. She said Resident #201 had a repaired [MEDICAL CONDITION] when she came back to the facility. MA G said Resident #201 would stay in bed and staff usually had to talk her into getting up. She said she would not refuse wound care or repositioning. During an interview on [DATE] at 2:15 p.m., CNA B said she had just started working there about the time Resident #201 was placed on the private hall. She said Resident #201 would yell out and sometimes resist changing, but they were always able to change her with encouragement, redirection and coming back later when she was not as agitated. During an interview on [DATE] at 2:20 p.m., LVN K said she only took care of Resident #201 a few times. LVN K said the resident yelled and hollered a lot. LVN K said Resident #201 never refused wound care. She said she was difficult to reposition because she would move back onto her back. During an interview on [DATE] at 4:32 p.m., LVN P said that Resident #201 would sometimes resist ADL care but after reattempting and encouragement, she would allow care. He said he found her low air loss mattress on a setting which he believed to be too firm and lowered it, hoping it would help with her pain. He said she would yell out a lot and staff would reposition her, but she always rolled back onto her back. He said the only time he knew of her being out of bed was during therapy. During an interview on [DATE] at 3:21 p.m., the ADON said Resident #201 did not like to be touched. She said staff would get her up at times, and she said they tried their best with repositioning her as she would refuse to be turned. During an interview on [DATE] at 3:30 p.m., the administrator said he expected staff to reposition residents at risk for pressure injuries. 2. Consolidated physician orders dated [DATE] to [DATE] indicated Resident #48 was [AGE] years old, admitted on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders required Resident #48 have weekly skin assessments on day shift every Friday. The physician orders indicated Resident #48's wound care orders for the stage 4 pressure injury on her sacrum were not routinely changed to promote healing and indicated the following wound care orders for the stage 4 on her sacrum: *from [DATE] to [DATE] - cleanse wound with normal saline, pack wound with alginate rope with silver and collagen, secure with dry dressing daily; *from [DATE] to [DATE] - cleanse wound with wound cleanser, pack with [MEDICATION NAME] rope and collagen, and secure with dry dressing daily; and *from [DATE] to [DATE] - cleanse wound to sacrum with normal saline, apply hypochlorite, apply collagen powder and loosely pack the wound with [MEDICATION NAME] gauze, and cover with a dry dressing daily. The physician orders did not indicate a treatment order for the stage 2 on her left thumb identified on [DATE]. The admission MDS dated [DATE] indicated Resident #48 admitted with one stage 4 pressure injury that measured 3.3 cm in length, 1.4 cm in width, and 1.2 cm in depth. The MDS indicated Resident #48's pressure injury wound bed had granulation tissue (pink or red with shiny, moist, granular appearance). The most recent MDS dated [DATE] indicated Resident #48 had clear comprehension, made herself understood, and was cognitively intact. The MDS indicated Resident #48 required total assistance with bed mobility, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #48 was at risk for developing pressure injuries. The MDS indicated Resident #48 had one stage 4 pressure injury present on admission. A care plan updated on [DATE] indicated Resident #48 was at risk for developing pressure injuries and had a stage 4 pressure injury on her sacrum. The care plan indicated Resident #48's pressure injury would show signs of healing and would remain free from infection. The care plan indicated the following interventions would be provided for Resident #48: *position with pillows to elevate pressure points off bed; *a skin inspection was completed every shift during routine care; *turn and reposition every 2 hours and as needed; *cleanse pressure injury with saline, apply hypochlorite gel, apply collagen powder, loosely pack the wound bed with [MEDICATION NAME] gauze and cover with dry dressing daily; *assess/record/monitor wound healing at least weekly and report decline to physician; and *avoid positioning resident on her back. Braden assessments for Resident #48 indicated the following: *on [DATE] - at risk for pressure injuries; *on [DATE] - at moderate risk for pressure injuries; *on [DATE] - at moderate risk for pressure injuries; and *on [DATE] - at risk for pressure injuries. A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx of at least 482 days duration measuring 2.2 cm x 1.8 cm x 0.7 cm with undermining (a pocket beneath the skin at the wound's edge) measuring 3.9 cm at 12 o'clock. The summary indicated the wound had moderate serous exudate with 20% slough (yellow or white tissue that adheres to the pressure injury bed in strings or thick clumps, or is mucinous), and 80% granulation tissue. The summary indicated there was no change in the wound. The summary indicated there was a surgical excisional debridement completed. A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx measuring 2 cm x 1.5 cm x 0.4 cm with undermining measuring 3.9 cm at 12 o'clock. The summary indicated the wound had light serous exudate with 20% slough and 80% granulation tissue. The summary indicated the wound had improved. The summary indicated there was a surgical excisional debridement A facility weekly skin assessment dated [DATE] indicated Resident #48's stage 4 pressure injury on her sacrum measured 2 cm x 1.6 cm x 0.6 cm with undermining of 3.9 cm at 12 o'clock and 3.5 cm at 9 o'clock, wound bed was pink or red with shiny, moist, granular appearance, had moderate drainage consisting of serum and blood, and had no odor. A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx measuring 1.82 cm x 1.7 cm x 0.7 cm with undermining measuring 4.5 cm at 12 o'clock. The summary indicated the wound had light serous exudate with 10% slough and 90% granulation tissue. The summary indicated the wound had improved. The summary indicated there was a surgical excisional debridement A facility skin assessment dated [DATE] indicated Resident #48's stage 4 pressure injury to her sacrum measured 2.2 cm x 1.7 cm x 0.7 cm with undermining of 3.9 cm at 12 o'clock and 3.7 cm at 9 o'clock, had moderate drainage consisting of serum and blood, and had no odor. A facility skin assessment dated [DATE] indicated Resident #48's stage 4 pressure injury to her sacrum measured 2 cm x 1.5 cm x 0.7 cm with undermining 4 cm at 12 o'clock and 3.8 cm at 9 o'clock, wound bed was pink or red with shiny, moist, granular appearance, moderate drainage consisting of serum and blood, and had no odor; A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx measuring 2 cm x 1.5 cm x 0.7 cm with undermining measuring 4 cm at 12 o'clock. The summary indicated the wound had light serous exudate with 10% slough and 90% granulation tissue. The summary indicated the wound had improved. The summary indicated there was a surgical excisional debridement. A wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #48 was in the hospital for a non-wound related event. A readmission skin assessment dated [DATE] indicated Resident #48's stage 4 pressure injury on her sacrum had scant bloody drainage and measured 2 cm x 2 cm x 0.7 cm with undermining of 3.9 cm at 12 o'clock. A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx measuring 2.1 cm x 1.5 cm x 0.8 cm with undermining measuring 4.3 cm at 12 o'clock. The summary indicated the wound had light serous exudate with 10 % slough and 90% granulation. The summary indicated the wound had improved. The summary indicated there was a surgical excisional debridement. A nursing note dated [DATE] at 4:55 p.m. indicated Resident #48 had an open area, with the top layer of skin missing at the base of her left dorsal thumb. The nurse's note did not indicate a new treatment was ordered for the new wound and did not describe or stage the area. The note indicated Resident #48's primary care physician was notified by fax. During an observation on [DATE] at 2:06 p.m., Resident #48 was lying in bed with her eyes closed, positioned on her right side, and a foul odor was noted. Resident #48's hands were crossed with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 3:33 p.m., Resident #48 was lying in bed, with her eyes closed, positioned on her right side, and had a moderate foul odor. Resident #48's hands were crossed with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 10:35 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted in her room. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 11:20 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted near her in her room. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left thumb. During an observation on [DATE] at 11:58 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 2:45 p.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an interview on [DATE] at 3:09 p.m., RN A said there was not enough staff to keep all the residents clean and dry and turned and repositioned every 2 hours. RN A said she had not worked in long term care in a very long time and did not have much training before having to work as the charge and wound treatment nurse. RN A said she was trained on the medication cart her first day, helped the other nurse gather vital signs the second day, and passed medication the third day of training. RN A said after the third day she was placed as the charge nurse and had to figure it all out. RN A said she felt she was constantly putting out fires, instead of being proactive because she did not have enough time. RN A said she was responsible for completing her residents' skin assessments and wound care treatments. RN A said she knew when residents' skin assessments were due because there was an order on the residents' physician orders. RN A said the CNAs filled out a shower sheet for any skin issues found during their showers, the nurses were responsible for looking at the shower sheets daily, and then the sheets were turned into the DON. RN A said any new areas observed were immediately reported

Based on observation, interview, and record review, the facility failed to provide nursing care with a sufficient number of nursing personnel with appropriate competencies and skills on a 24-hour basis to provide nursing care for all residents in accordance with resident care plans for 6 of 12 residents reviewed for pressure injuries and nursing services. (Resident #'s 201, 48, 16, 33, 49, 102) The facility did not provide sufficient staff to complete weekly skin assessments and turn and reposition Resident #201 to promote the healing and prevent worsening of a stage 3 pressure injury on her sacrum. The facility did not provide staff with appropriate competencies to provide wound care to promote healing and prevent infections of Resident #48's stage 4 pressure injury and provide sufficient staff to turn and reposition the resident to prevent development of a new pressure injury. The facility did not provide sufficient staff to turn and reposition Resident #16 to promote the healing and the worsening of a stage 3 pressure injury to the sacrum. The facility did not provide sufficient staff to turn and reposition Resident #33 to prevent the development of two new pressure injuries to her left elbow and left knee and provide staff with knowledge of the correct settings for the Resident 33's low air loss mattress. The facility did not provide sufficient staff with appropriate competencies to regularly assess Resident #49's skin regularly, identify new pressure injuries, recognize significant weight loss and turn and reposition the resident. The facility failed to provide staff with appropriate competencies to ensure Resident #102's blood sugars were appropriately monitored. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE] at 5:20 p.m., the facility remained out of compliance at a pattern of actual harm due to the facility's need to complete in-service training and evaluate the effectiveness of corrective systems. This failure could place residents at risk of not receiving care and services to meet their needs, illness and death. Findings included: The facility assessment updated [DATE] indicated overall the resident population required assistance with ADLs as follows: *Dressing - 42 residents assist of ,[DATE] staff; 6 residents are dependent upon staff. *Bathing - 42 residents require assist of ,[DATE] staff; 17 residents are dependent upon staff. *Transfer - 41 residents require assist of ,[DATE] staff; 6 residents are dependent upon staff. *Eating - 48 residents require assist of ,[DATE] staff; 1 resident is dependent upon staff. *Toileting - 35 residents require assist of ,[DATE] staff; 14 residents are dependent upon staff. The facility assessment updated [DATE] indicated the general staffing plan to ensure sufficient staff members to meet the needs of residents at any given time was as follows: *RN or LPN charge nurse: 3 for each shift *1:17 licensed nurse ratio days and evenings *1:26 licensed nurse nights *Direct care staff members: 1:5 ratio days; 1:8 ratio evenings; 1:10 ratio nights. 1. A face sheet dated [DATE] indicated Resident #201 was [AGE] years old and admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The face sheet indicated Resident #201 was discharged from the facility on [DATE] for surgical debridement of her sacral pressure injury. Physician orders [REDACTED].#201 had wound care orders for the sacral pressure injury to cleanse with normal saline, apply Santyl to wound and cover with dry dressing every day, low air loss mattress, pressure reduction device to bed and or chair, reposition Resident #201 every two hours and as needed and avoid pressure to sacrum. A significant change MDS dated [DATE] indicated Resident #201 had clear speech, was able to understand others and could make herself understood. Resident #201 had moderate cognitive impairment and was incontinent of bowel and bladder. Resident #201 had verbal behaviors directed towards others and would intrude on the privacy or activity of others and would significantly disrupt care or living environment. The MDS indicated Resident #201 required extensive assistance of two staff members for bed mobility. The MDS indicated the resident required extensive assistance of one staff member for dressing, limited assistance for eating and was dependent on staff for personal hygiene. The MDS indicated Resident #201 was at risk for developing pressure injuries and had one unhealed pressure injury, stage 3 upon admission. Hospital records dated [DATE] indicated Resident #201 was being treated at a behavioral hospital and fell then admitted to the hospital for a [MEDICAL CONDITION] and the hip was repaired on [DATE]. The records indicated Resident #201 did not have any pressure injuries and there was not a [DIAGNOSES REDACTED]. A care plan dated [DATE] indicated staff would assist Resident #201 with turning and repositioning as needed while in bed. The care plan indicated staff would shower Resident #201 three times per week and as needed. The care plan indicated a low-air loss mattress was placed on her bed on [DATE]. The care plan indicated staff would assess Resident #201's skin weekly per the facility policy. The care plan indicated staff would off-load her heels and would turn and reposition Resident #201 as needed and with each incontinent episode. The care plan indicated staff would position Resident #201 with pillows to elevate pressure points off the bed. The care plan updated on [DATE] indicated Resident #201 had a sacral wound, and she did not have a catheter. The initial wound care specialist evaluation dated [DATE] indicated Resident #201 had a stage 3 sacral wound that measured 3 cm length, 5 cm in width, and 0.2 cm in depth. The description included light serous drainage and 100% slough. The wound care orders were for Santyl once a day with a foam border dressing. A nursing note dated [DATE] indicated Resident #201 yelled out as usual with all care provided. A nursing note dated [DATE] indicated Resident #201 continued to scream she was hurting, and the physician was notified. The nursing note indicated yelling could be a behavioral episode and the physician referred Resident #201 to behavioral care and to inform the behavioral physician. A nursing note dated [DATE] indicated Resident #201 yelled out and was screaming because she wanted to get out of bed. The note did not indicate if Resident #201 was gotten out of bed. A notification of change in condition, dated [DATE], indicated the facility notified the physician Resident #201's pain was not managed related to Resident #201 yelling and crying out during the entire shift, after pain medications were given. The note indicated the physician said he was told the day before the resident was ok. The physician increased the resident's [MEDICATION NAME] to 2 tablets every 6 hours, as needed for pain. A nursing note dated [DATE] indicated Resident #201 yelled and complained of buttocks pain, and Resident #201's cognitive status did not allow her to verbalize understanding of repositioning, and the risk of worsening pressure injury. A nursing note dated [DATE] indicated Resident #201 yelled out and complained of buttocks pain. The note indicated medication and repositioning were effective and Resident #201 continued to yell out when care was provided. A nursing note dated [DATE] indicated Resident #201 shouted at staff to get her up or yelled for her husband to come get her. The note did not indicate if staff assisted Resident #201 to get up. A notification of change in condition dated [DATE] sent to the physician indicated Resident #201 continued to scream out for most of the time she was awake. The note indicated the current medications were [MEDICATION NAME] 7.5 mg every 6 hours as needed for pain, [MEDICATION NAME] 100 mg every 6 hours as needed for pain, and [MEDICATION NAME] 25 mg twice a day. The communication indicated the nurse believed pain was present although Resident #201 denied pain and yelled to be gotten up. The communication did not indicate Resident #201 was assisted to get up. A notification of change in condition dated [DATE] sent to indicated Resident #201 had a large amount of purulent, thick, brown, foul smelling drainage and area surrounding wound was red and warm on her sacral pressure injury. The physician responded, why was I not notified when I was in the facility this morning, something like this needs surgery. A nursing note dated [DATE] indicated Resident #201's physician was notified of the wound condition and changed wound care orders to include; apply Santyl, pack loosely with packing strip and cover with dry dressing and obtain a wound culture. Physician orders [REDACTED].#201's sacral wound to be cleansed with wound cleanser, apply [MEDICATION NAME], and fill wound bed loosely with packing and cover twice per day. A notification of change of condition sent to the physician dated [DATE] indicated Resident #201's stage 3 wound to her sacrum was scheduled for debridement and a urinary catheter was inserted. A wound culture report dated [DATE] indicated Resident #201 had proteus mirabilis and Escherichia coli (bacteria found in the digestive tract) in her wound. A notification of change of condition sent to the physician dated [DATE] indicated Resident #201 was admitted to the hospital for sharp debridement of the sacral wound. A hospitalist progress note dated [DATE] indicated Resident #201 was admitted to the hospital on [DATE] for clearance for outpatient surgical debridement of sacral ulcer. The note indicated the resident presented on a stretcher screaming in pain and was severely demented. The note indicated she was frail and cachectic (general ill health with emaciation), was in distress and had a smell of necrotic (death of tissue) flesh with purulent (containing pus) exudate (a fluid) oozing from her sacrum. The noted indicated Resident #201 had a stage 4 sacral ulcer to the bone with bubbles and exudate that was spontaneously dripping all over the hospital bed. The assessment and plan in the note indicated Resident #1 [MEDICAL CONDITION], a stage 4 sacral pressure injury with gas gangrene, [MEDICAL CONDITION](high heart rate), severe dementia, debility with contractures, acute kidney injury, stage ,[DATE] [MEDICAL CONDITION], and severe protein calorie malnutrition. An inpatient discharge summary dated [DATE] indicated Resident #201 came in [MEDICAL CONDITION] due to gas gangrene of her sacrum with sacral ulcer. The summary indicated she was found to have poor quality of life and very poor chances of healing or improving, and her family opted for inpatient hospice. The summary indicated Resident #201 expired at 6:38 a.m. on [DATE]. During an interview on [DATE] at 9:39 a.m., the complainant said that Resident #201 was admitted to a hospital for debridement of a sacral pressure injury that tested positive for a bacterial infection. She said the wound was open, draining foul, brown, exudate and her bone was exposed. The complainant said Resident #201 was admitted to the hospital for severe dehydration and gangrene (death of body tissue due to either lack of blood flow or a serious bacterial infection) to her wound. She said the hospitalist told her that Resident #201 would probably not recover. She was placed on hospice at the hospital and passed away on [DATE]. During an interview on [DATE] at 2:51 p.m., RN L said Resident #201 did not understand to stay repositioned or offloaded to her side. He said he was able to reposition Resident #201 when she was asleep. He said when she was awake she was constantly moving, and she would wiggle back onto her back, he said he thought it was because of pain. He said if Resident #201 resisted ADLs or wound care, he would re-approach and attempt later. He said he always managed to get her wound care done. During an interview on [DATE] at 9:45 a.m., CNA F said she had worked here approximately 5 months. She said it was herself and another aide for all 3 halls with approximately 36 residents between the 2 of them. She said she knew residents were supposed to be turned every 2 hours, but the aides were unable to routinely do this. She said they could not keep up with resident care. During an interview on [DATE] at 10:20 a.m., CNA F said it was very hard to keep all the residents repositioned every 2 hours. She said staff tried to get it all done but that there were many dependent residents. CNA F said aides must prioritize the call lights because there aren't enough aides to answer the lights promptly. CNA F said she hated to make a resident sit in a soiled brief after an incontinent episode because she was busy cleaning up a resident who vomited. CNA F said the facility needed more staff to prevent skin breakdown and pressure injuries. During an interview on [DATE] at 2:04 p.m., RN A said aides were responsible for repositioning dependent residents. She said she had not monitored them to ensure they were doing it because she as very overwhelmed with other resident care since she was the only nurse on the floor. RN A said the facility did not have enough staff to effectively care for the residents. During an interview on [DATE] at 2:00 p.m., MA L said that Resident #201 was very vocal, and yelled out all the time. She said Resident #201 would not refuse care including turning and repositioning, she said she would sometimes try to resist care, but staff could usually talk her into letting them provide incontinent care and reposition her. During an interview on [DATE] at 4:32 p.m., LVN P said that Resident #201 would sometimes resist ADL care but after reattempting and encouragement, she would allow care. He said she would yell out a lot and staff would reposition her, but she always rolled back onto her back. During an interview on [DATE] at 3:21 p.m., the ADON said Resident #201 did not like to be touched. She said staff would get her up at times, and she said they tried their best with repositioning her as she would refuse to be turned. During an interview on [DATE] at 3:30 p.m., the administrator said he expected staff to reposition residents at risk for pressure injuries. 2. Consolidated physician orders [REDACTED].#48 was [AGE] years old, admitted on [DATE], and re-admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The physician orders [REDACTED]. saline, apply hypochlorite, apply collagen powder and loosely pack the wound with [MEDICATION NAME] gauze, and cover with a dry dressing daily. The most recent MDS dated [DATE] indicated Resident #48 had clear comprehension, made herself understood, and was cognitively intact. The MDS indicated Resident #48 required total assistance with bed mobility, dressing, eating, toileting, and personal hygiene. The MDS indicated Resident #48 was at risk for developing pressure injuries. The MDS indicated Resident #48 had one stage 4 pressure injury present on admission. A care plan updated on [DATE] indicated Resident #48 was at risk for developing pressure injuries and had a stage 4 pressure injury on her sacrum. The care plan indicated Resident #48's pressure injury would show signs of healing and would remain free from infection. The care plan indicated the following interventions would be provided for Resident #48: *position with pillows to elevate pressure points off bed; *a skin inspection was completed every shift during routine care; *turn and reposition every 2 hours and as needed; *cleanse pressure injury with saline, apply hypochlorite gel, apply collagen powder, loosely pack the wound bed with [MEDICATION NAME] gauze and cover with dry dressing daily; *assess/record/monitor wound healing at least weekly and report decline to physician; and *avoid positioning resident on her back. A wound evaluation and management summary dated [DATE], completed by a wound care NP indicated Resident #48 had a stage 4 pressure wound on her coccyx measuring 2.2 cm x 1.3 cm x 0.8 cm with undermining measuring 4.3 cm at 12 o'clock. The summary indicated the wound had light serous exudate with 10 % slough and 90% granulation. The summary indicated the wound had improved. The summary indicated there was a surgical excisional debridement. A nursing note dated [DATE] at 4:55 p.m. indicated Resident #48 had an open area, with the top layer of skin missing at the base of her left dorsal thumb. The nurse's note did not indicate a new treatment was ordered for the new wound and did not describe or stage the area. The note indicated Resident #48's primary care physician was notified by fax. During an observation on [DATE] at 2:06 p.m., Resident #48 was lying in bed with her eyes closed, positioned on her right side, and a foul odor was noted. Resident #48's hands were crossed with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 3:33 p.m., Resident #48 was lying in bed, with her eyes closed, positioned on her right side, and had a moderate foul odor. Resident #48's hands were crossed with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 10:35 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted in her room. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 11:20 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted near her in her room. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left thumb. During an observation on [DATE] at 11:58 a.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an observation on [DATE] at 2:45 p.m., Resident #48 was lying in bed on her back, and a moderate foul odor was noted. Resident #48's hands were crossed across her stomach with the edge of her right hand positioned on top of the base of her left dorsal thumb. During an interview on [DATE] at 3:09 p.m., RN A said there was not enough staff to keep all the residents clean and dry and turned and repositioned every 2 hours. RN A said she had not worked in long term care in a very long time and did not have much training before having to work as the charge and wound treatment nurse. RN A said she was trained on the medication cart her first day, helped the other nurse gather vital signs the second day, and passed medication the third day of training. RN A said after the third day she was placed as the charge nurse and had to figure it all out. RN A said she felt she was constantly putting out fires, instead of being proactive because she did not have enough time. RN A said she was responsible for completing her residents' skin assessments and wound care treatments. During an observation and interview on [DATE] at 3:18 p.m., Resident #48 was lying in bed on her back and a foul odor was noted. Resident #48's hands were crossed across her stomach, with the edge of her right hand positioned on top of the base of her left dorsal thumb. Resident #48's left hand at the base of her thumb had a clear dressing over a wound measuring approximately 2 cm in length and 2 cm in width. The wound had yellow drainage covering the wound bed. The surrounding tissue was bright red. RN A said she discovered an open blister on the area on [DATE]. RN A said she did not know the facility's policy on staging wounds and did not stage the area. RN A said Resident #48 kept her hands together most of the time which contributed to the area being open. Resident #48 was positioned on her right side and a strong, foul, odor was noted. RN A removed Resident #48's old dressing from the Stage 4 pressure injury on the resident's sacrum, and a very strong, foul odor engulfed the room. The old dressing was saturated with brown drainage, and large amounts of yellow and brown drainage was on Resident #48's brief. RN A said the yellow and brown drainage on Resident #48's brief was wound drainage. RN A cleaned the wound with normal saline and measured the wound as 2.5 cm in length, 2 cm in width, 0.8 cm in depth, and undermining 3 cm at 12 o'clock. The wound bed that was visible was pink and red, the undermining wound bed was unable to be visualized. While RN A measured the wound, white packing fell out of the wound edge to the wound opening. RN A gathered new packing strips and collagen mixture and proceeded to pack the wound without removing the old packing. When asked what the substance was in the wound, RN A said it was the old packing. She removed the old packing, cleaned the wound with normal saline, and placed new packing and collagen mixture in a ball shape on the wound surface. RN A did not pack the undermining or all the wound bed. The pressure injury was covered with a dry dressing. During wound care, RN A did not wash or sanitize her hands between glove changes. During an interview on [DATE] at 3:35 p.m., CNA B said there were not enough staff to keep the residents turned and repositioned every 2 hours. During an observation on [DATE] at 10:05 a.m., Resident #48 was lying in bed on her right side, her hands were together with her right hand on top of left hand at the base of her thumb at the pressure injury site. During an interview on [DATE] at 10:15 a.m., the ADON said the charge nurses were responsible for completing skin assessments and performing their own pressure injury treatments. The ADON said the charge nurses had no formal pressure injury training. The ADON said the residents had an order that indicated when their skin assessments were due. The ADON said she did not know why there were missing skin assessments and the DON was responsible for monitoring the skin assessments were completed. The ADON said the nurses were supposed to notify the residents' physician immediately when a new or changed pressure injury was identified. During an interview on [DATE] at 10:13 a.m., CNA C said residents were supposed to be turned and repositioned at least every 2 hours. CNA C said they were not able to turn and reposition residents every 2 hours because there were not enough staff. CNA C said Resident #48 had pressure injuries and needed to be turned every 2 hours. CNA C said she was employed at the facility's sister facility and was in working in this facility to help them out because they did not have enough staff. During an interview on [DATE] at 10:18 a.m., LVN D said residents were supposed to be turned and repositioned at least every 2 hours. LVN D said she was helping in the facility today but normally worked in a sister facility. During an interview on [DATE] at 10:21 a.m., CNA [NAME] said Resident #48 should not be positioned on her back and should have a pillow between her hands. CNA [NAME] said residents were supposed to be turned and repositioned at least every 2 hours but were unable to because there were not enough staff. During an interview on [DATE] at 11:14 a.m., CNA F said residents should be turned and repositioned at least every 2 hours, but they were not able to because there were not enough staff. During an observation and interview on [DATE] at 11:25 a.m., Resident #48 was lying on her right side and her right hand was positioned on the base of her left-hand thumb at the pressure injury site. Resident #48 had a rag in her right hand that was resting on her left wrist and caused a blanchable red area. RN A said Resident #48 should be turned and repositioned every 2 hours but had not been because there was not enough staff to keep everyone turned. RN A said Resident #48 should not be positioned on her back. RN A said Resident #48 should have a pillow between her hands to prevent pressure injuries. RN A said the new area on the base of Resident #48's left thumb was a stage 2. RN A said the odor from Resident #48's stage 4 pressure injury on her coccyx during the treatment change on [DATE] was necrotic tissue and possibly infection. RN A said during the treatment change on [DATE] she almost left the old packing in the wound because she thought the wound had one strip of packing instead of two. RN A said she did not wash or sanitize her hands between changing gloves during Resident #48's pressure injury dressing change. RN A said she should have washed her hands between changing her gloves. During an interview on [DATE] at 1:46 p.m., the ADON said she knew there was a staffing problem and had been working as a charge nurse frequently. During an interview on [DATE] at 3:58 p.m., the administrator said he expected adequate staff to be scheduled, residents to be turned at least every 2 hours, appropriate pressure injury treatments to be in place, and the physician to be notified of changes in pressure injuries. 3. Consolidated physician orders [REDACTED].#16 was [AGE] years old, and admitted on [DATE] with [DIAGNOSES REDACTED]. The physician orders [REDACTED].#16 had weekly skin assessments every Wednesday on the night shift. The physician orders [REDACTED].#16's weekly skin assessments would be every Friday on the day shift. The physician orders [REDACTED]. The physician orders [REDACTED]. The most recent MDS dated [DATE] indicated Resident #16 sometimes understood others, sometimes made herself understood, and had severe cognitive impairment. The MDS indicated Resident #16 required extensive assistance with eating, and total assistance with bed mobility, transferring, dressing, toileting, personal hygiene, and bathing. The MDS indicated Resident #16 was at risk for developing pressure injuries and had one existing stage 2 pressure injury not present on admission. A care plan dated [DATE] indicated Resident #16 was at risk for pressure injuries due to decreased mobility, chair fast, and incontinence. The care plan indicated Resident #16's skin would remain intact without evidence of redness, irritation, maceration, or open areas. The care plan did not address turning and repositioning. A care plan dated [DATE] indicated Resident #16 had a stage 3 pressure injury on her sacrum. The care plan indicated Resident #16's pressure injury would not exhibit signs of infection, had dressing changes as ordered by the physician and indicated Resident #16 had weekly skin assessments and to report signs of further skin breakdown. The care plan did not address turning and repositioning. A wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #16 had a stage 3 pressure injury on her sacrum measuring 1.6 x 1 x 0.1 cm with light serous exudate. The evaluation indicated 20% slough and 80% granulation tissue. The note indicated the wound had deteriorated During an observation and interview on [DATE] at 11:35 a.m., Resident #16's stage 3 pressure injury measured 3.8 cm in length, 2.5 cm in width, and approximately 0.2 cm in depth. The wound bed was pink with a small amount of slough, no odor. The wound edges were black eschar (dead tissue). RN A said Resident #16's pressure injury had worsened since [DATE]. RN A said Resident #16's wound edges did not have eschar and the wound bed did not have slough on [DATE]. RN A said the pressure injury was unstageable. During an interview on [DATE] at 2:01 p.m., Resident #16's wound care nurse practitioner (NP) said he had not been notified of changes in Resident #16's sacrum pressure injury. The NP said he saw Resident #16's sacrum pressure injury on [DATE] and there was no necrotic tissue or eschar surrounding the wound. The NP said he should have been notified of the changes immediately. During an interview on [DATE] at 1:46 p.m., the ADON said she expected Resident #16's physician and/or wound care nurse practitioner to be notified of changes or worsening of her pressure injury. The ADON said she expected Resident #16's skin to be consistently assessed weekly. During an interview on [DATE] at 3:58 p.m., the administrator said he expected residents to be turned at least every 2 hours, appropriate pressure injury treatments to be in place, and the physician to be notified of changes in pressure injuries. 4. A face sheet, dated [DATE] indicated Resident #33 was admitted on [DATE] with [DIAGNOSES REDACTED]. An MDS dated [DATE] indicated Resident #33 was understood and understand others and had a BIMS score of 5 indicating severe cognitive impairment. The MDS indicated she required extensive assistance with two-person physical assist for bed mobility, transfers, toilet use and personal hygiene. The MDS indicated Resident #33 was always incontinent of bladder and bowel and was at risk of pressure ulcers. A care plan dated [DATE] indicated Resident #33 was at risk for pressure ulcers. Interventions included skin inspection every shift during routine ADL care, she would be turned every 2 hours, a low air loss mattress and keep resident off bony prominences as she would allow. An initial wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #33 had an unstageable sacrum wound measuring 3 x 3.6 x 0.3 cm with light serous exudate. The summary indicated the wound had 100% adherent devitalized necrotic tissue and surgical excisional debridement was completed. A wound evaluation and management summary dated [DATE] completed by a wound care NP indicated Resident #33 had an unstageable wound to her sacrum measuring 4 x 2.5 x 0.4 cm with moderate serous exudate. The evaluation indicated the wound had 100% thick adherent devitalized necrotic tissue and the wound had improved. The evaluation indicated a surgical excisional debridement was completed. The evaluation indicated Resident #33 had a DTI to her right heel measuring 4 cm x 8 cm. During an observation on [DATE] at 11:35 a.m. Resident #33 was lying in bed on her left side. The low air loss mattress pump was set to 9, the firmest setting. During an observation on [DATE] at 2:00 p.m., Resident #33 was lying in bed on her left side. The low air loss mattress was set at 9. During an observation on [DATE] at 10:55 a.m., Resident #33 was lying in bed on her left side. The low air loss mattress was set at 9. During an observation on [DATE] at 2:19 p.m., Resident #33 was lying on her left side and the low air loss pump was set on 9. During an observation on [DATE] at 2:45 p.m., RN A performed routine wound care and a skin assessment for Resident #33. RN A identified a pressure injury to Resident #33's left elbow measuring 1.8 cm in length x 1.8 cm in width, and a pressure injury on Resident #33's left knee measuring

Based on observation, interview, and record review, the facility failed to provide supervision to prevent accidents for 1 of 10 residents reviewed for accidents. (Resident #3) Resident #3 was at risk for falls. He was injured when he fell while being prepared for transfer. Staff did not provide support as required when transferring Resident #3. Resident #3 was transferred to the hospital and received 15 sutures. This failure contributed to Resident #3's injury and could place 36 residents who were dependent on staff for transfers at risk for injury. Findings included: Physician orders [REDACTED]. The MDS dated [DATE] indicated Resident #3 was severely cognitively impaired, totally dependent on two staff for transfers and had a history of [REDACTED]. The MDS indicated Resident #3 was only stable with staff assistance when moving from a seated to a standing position and when making surface to surface transfers. An incident report dated 10/2/12 indicated CNA P dressed Resident #3 and sat him on the side of the bed. When CNA P turned around to reposition a chair, Resident #3 fell from the bed to the floor striking his head on a dresser. Resident #3 was taken to the hospital for a laceration to the right side of his forehead. The care plan dated 10/11/12 indicated Resident #3 had a potential for falls due to unsteady balance and a history of falls. The care plan interventions required the assistance of two staff and a mechanical lift as needed for transfers but did not include interventions to address Resident #3's balance problems. An incident report dated 10/23/12 indicated LVN B was called to the room by a CNA and Resident #3 was sitting in the floor beside the bed with blood on his right outer eye and shirt. The incident report indicated he had a small abrasion on his right cheek and a 5.3 cm laceration on his right outer eye. A CNA was "standing at bedside directly beside resident looking down removing gait belt to place on resident, resident started leaning forward/falling, CNA directly beside resident went to grab resident as he was falling and was unable to get a good hold. Resident fell to floor at this time." The report indicated Resident #3 was transported to the hospital by ambulance. The progress notes following the report indicated Resident #3 would be transferred using a mechanical lift at all times. No other interventions were addressed. A care plan updated 10/23/12 indicated Resident #3 had a laceration on his right outer eye with 15 sutures and required a mechanical lift to be used with all transfers. The care plan not include interventions to address Resident #3's balance problems. During an observation and interview on 11/13/12 at 8:25 a.m., Resident #3 had an approximately three inch pink scar above his right eye. His family member said Resident #3 fell during a transfer and had to receive 15 sutures. The family member said Resident #3 had to be taken to the hospital twice in one month after falling during a transfer. The family member said Resident #3 now required a mechanical lift to be used with all transfers instead of "just when needed". During an interview on 11/13/12 at 10:45 a.m., CNA A said CNA C told her she (CNA C) was using her knee to hold Resident #3 on the side of the bed while she removed a gait belt from her waist when he fell to the side and landed on the floor. During an interview on 11/14/12 at 9:02 a.m., CNA C said on 10/23/12, she was in Resident 3's room with two other CNAs. She said one CNA was making Resident #3's roommate's bed and the other CNA was moving the Geri chair closer to transfer Resident #3 from the bed. CNA C said she sat Resident #3 on the side of his bed and she was holding him in place with her knee while she removed a gait belt from her waist. CNA C said she did not have her hands on Resident #3 while she was removing the gait belt. She said Resident #3 began to fall and she was unable to catch him. She said Resident #3 required two staff to transfer him because he was unable to balance himself. She said she had never used a mechanical lift to transfer Resident #3 prior to his 10/23/12 fall. She said she was told Resident #3 required a mechanical lift with all transfers following his 10/23/12 fall. During an interview on 11/14/12 at 8:45 a.m., LVN B said Resident #3 fell twice in one month during transfers and was taken to the hospital with injuries. LVN B said Resident #3 now required a mechanical lift to be used with all transfers. She said Resident #3 did not have the ability to balance himself and should not have been sat on the side of the bed until the CNAs were ready to transfer him. During an interview on 11/14/12 at 9:55 a.m., the DON said she had not trained the staff involved with Resident #3's fall because she did not feel they were at fault. She said the only intervention put into place after his second fall was Resident #3 now required a mechanical lift to be used with all transfers. She said she had not trained staff on the proper way to transfer Resident #3. The transfer policy dated 9/21/12 indicated "depending upon amount of assistance required, you may either support the resident on his/her affected side or stand in front of the resident" and "when transferring a resident who was unable to assist equipment should be placed at bedside, obtain assistance from another staff for safe transfer." The policy did not address specific techniques for residents with impaired balance. The CMS 672 dated 11/13/12 indicated 36 residents were dependent on staff for transferrs.