Every finding on record at Blossom Healthcare & Rehabilitation Center

Based on observation, staff interviews, and review of the facility policy titled Dating & Expired Food Items Policy, the facility failed to ensure that food items were dated when opened. In addition, the facility failed to ensure that food items were not stored or made available for use beyond their expiration dates. The deficient practices had the potential to place the 81 residents who received food and hydration from the kitchen at increased risk of foodborne illness. Findings include: Review of the facility's undated policy titled Dating & Expired Food Items Policy revealed the Policy Statement included, The facility will ensure all food is identifiable, within allowed dates, and safe for service to prevent use of expired, undated, or questionable items. Every food item will be labeled and dated at receipt and when opened/ prepared, with a clear discard date. No item may be served past its use-by/discard date. Updated, unlabeled, or questionable items will be discarded immediately. Observation during the initial kitchen tour on 1/6/2026 from 8:35 am to 9:05 am, with the Dietary Manager (DM) present, revealed the following: Two freezer bags of chicken, unlabeled and missing a use-by/discard date. One freezer bag of chopped ham was labeled with an expired date of 1/4/2026. One plastic container of gravy, missing a use-by date One bag of opened, cut potatoes in a box with no open or use-by date present. In an interview on 1/6/2026 at 9:05 am, the DM confirmed that the chopped ham had expired and stated that staff forgot to throw it out on 1/4/2026. The DM stated the chicken should have been labeled with an open and discard date, and that all open food items should have an open and discard date.

Based on observations, staff interviews, and review of the facility's policies titled Medication Storage in the Healthcare Centers and Medication Administration: General Guidelines, and Medication Administration: General Guidelines, the facility failed to ensure one of three medication carts and one of one wound care cart were locked and secured when out of the direct sight of the nurse. In addition, the facility failed to discard expired medical supplies in one of four supply rooms. Additionally, the facility failed to ensure that medications on two of three medication carts were stored in a sanitary manner. These deficient practices have the potential to place residents residing in the facility at risk of unauthorized access to medications, use of expired medical supplies, and avoidable infection related to cross-contamination. The census was 80 residents. Findings include:Review of the facility's policy titled Medication Storage in the Healthcare Centers, revised [DATE], revealed that the Policy Statement included, Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, Certified Medication aides, and pharmacy personnel. The Procedure section included, .3. Nurses and medication aides are required to check all medications for deterioration and expiration before administration. Nursing staff and medication aides who administer medications are responsible for the cleaning and organization of medication carts and storage areas. 11. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy if a current order exists.Review of the facility's policy titled Medication Administration: General Guidelines, reviewed [DATE], revealed the Procedure section included, . 16. During routine administration of medications, the medication cart is kept closed and locked. No medications are kept on top of the cart must be inaccessible to patients/residents or others passing by.1. Observation on [DATE] at 9:10 am revealed Licensed Practical Nurse (LPN) LL entered resident room [ROOM NUMBER] to administer medication. Observation revealed the medication cart located in the hallway was unlocked and unattended, and out of the direct eyesight of LPN LL. Further observation revealed that medications were on top of the cart. In an interview on [DATE] at 9:12 am, LPN LL confirmed that she did not lock the medication cart, there were medications on top of the cart, and that the cart was not in her view. She stated that the medication cart should be locked if not in use or in view, and medications should not be left on top of the cart. Observation on [DATE] at 10:59 am revealed that the wound care cart on the 100 Hall was unlocked and unattended. In an interview on [DATE] at 11:00 am, LPN DD confirmed that the wound care cart located on the 100 Hall was unlocked and unattended. She stated that the cart should be locked because it contained medications.2. In a concurrent observation and interview on [DATE] at 12:30 pm, during observation in the Wound Care Room, the Central Supply/Staffing Coordinator confirmed disinfectant wipes expired on 2/2025, and xeroform gauze dressing (wound care dressing) expired on 3/2024.Observation on [DATE] at 12:57 pm, in the Medication Room, located at Nurse's Station Two, revealed sting-free expired [DATE], derma prep expired [DATE], and disinfectant wipes expired 9/2025. In an interview on [DATE] at 12:58 pm, the Central Supply/Staffing Coordinator confirmed the expired sting-free, derma prep, and disinfectant wipes.3. Observation on [DATE] at 11:20 am of the medication cart located on the 100 Unit, revealed one inhaler was stored with no mouthpiece cover, one nasal spray with no cover on the top, and one mouth spray with no cover on the top.Observation on [DATE] at 3:08 pm of the medication cart located on the 300 Unit revealed one nasal inhaler with the top cover missing. In an interview on [DATE] at 11:40 am, LPN AA confirmed the findings on the medication cart on the 100 Unit. In a concurrent interview on [DATE] at 3:07 pm, LPN LL and the Assistant Director of Nursing (ADON) confirmed that the nasal spray on the 300 Unit medication cart was missing a cover.In a concurrent observation and interview on [DATE] at 11:40 am of a medication cart with LPN AA, she confirmed the cart had a sticky substance on it, and a medication box was stuck to the bottom of a drawer of the cart. She stated the nurses should maintain the carts in a clean condition. In an interview on [DATE] at 1:16 pm, LPN DD stated that the nurse who works on the cart was to keep the cart clean.In an interview on [DATE] at 3:23 pm, the Director of Nursing (DON) stated that the Central Supplier personnel stock and check the over-the-counter medication and should check the expiration dates of the supplies. The DON stated that the nurses were responsible for checking medication carts for expired medication and ensuring they were clean. The DON further stated that nurses should lock the medication cart when they walk away from it and should not leave medications on top of the medication cart.

Based on observations, staff interviews, record review, and review of the facility's policy titled Oxygen Therapy Policy, the facility failed to ensure four of 29 residents (R) (R43, R46, R76, and R4) with oxygen orders received oxygen as ordered by the physician. This deficient practice has the potential to place residents R43, R46, R76, and R4 at increased risk of respiratory complications.Findings include: Review of the facility's policy titled Oxygen Therapy Policy, revised 4/2024, revealed the policy statement was, It is the policy of the facility that oxygen therapy was administered per a physician's order or as an emergency measure until a physician's order can be obtained. The Follow the steps below to administer oxygen therapy section included, .8. Turn on the oxygen supply and set the flow meter to the rate ordered by the physician. 1. Review of the Quarterly Minimum Data Set (MDS) assessment for R43, dated 10/13/2025, revealed Section I (Active Diagnosis) documented diagnoses including chronic obstructive pulmonary disease (COPD) and obstructive hypertrophic cardiomyopathy. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the medication administration record (MAR), dated 1/1/2026 through 1/31/2026, for R43 revealed an order dated 9/20/2024 for oxygen at 3 LPM via NC, as tolerated per resident, every shift and every day. Observations on 1/6/2026 at 10:12 am and 1/7/2026 at 7:25 am revealed that R43 was receiving oxygen via an NC, and the concentrator flow rate was set between 4 and 4.5 LPM. Observation on 1/8/2026 at 8:31 am revealed that R43 was receiving oxygen via an NC, with the concentrator flow rate set to 4 LPM. In an interview on 1/8/2026 at 10:34 am, Licensed Practical Nurse (LPN) Unit Manager (UM) II confirmed that R43's oxygen flow rate was set between 4 and 4.5 LPM. She stated that the nurse should ensure the oxygen flow rate was set to the physician-ordered setting. 2. Review of the Quarterly MDS for R46, dated 11/25/2025, revealed Section I (Active Diagnosis) revealed diagnoses including chronic diastolic heart failure and generalized anxiety disorder. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the physician orders for R46 revealed an order dated 12/2/2025 for oxygen at 2 LPM via NC as needed. Observation on 1/6/2026 at 9:35 am revealed that R46 was receiving oxygen, with the concentrator flow rate set between 4 and 4.5 LPM. Observation on 1/7/2026 at 7:22 am revealed that R46 was receiving oxygen, with the concentrator flow rate set at 3.5 LPM. Observation on 1/8/2026 at 8:29 am revealed that R46 was receiving oxygen, and the concentrator was set between 3 and 3.5 LPM. In a concurrent interview and observation on 1/8/2026 at 10:35 am, LPN/UM II confirmed that the oxygen flow rate for R46 was set between 4 and 4.5 LPM. She confirmed that the physician's order was for 3 LPM, and the flow rate was not set to the correct level. 3. Review of the Quarterly MDS for R76, dated 10/27/2025, revealed Section I (Active Diagnosis) revealed diagnoses including chronic obstructive pulmonary disease (COPD) and acute respiratory distress. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the physician orders for R76 revealed an order dated 10/14/2025 for oxygen at 2LPM via NC as needed and as tolerated per resident every shift. Observation on 1/6/2026 at 10:11 am revealed that R76 was receiving oxygen, with the concentrator flow rate set to 3 LPM. Observation on 1/7/2026 at 7:20 am revealed that R76 was receiving oxygen, with the concentrator flow rate set at 3.5 LPM. In a concurrent interview and observation on 1/8/2026 at 10:32 am, LPN/UM II confirmed the concentrator flow rate for R76 was set at LPM. She confirmed that the physician's order was for oxygen therapy at 2 LPM. In an interview on 1/8/2026 at 10:42 am, LPN/UM II stated that she checked oxygen flow rates on concentrators after medication pass. In an interview on 1/8/2026 at 1:42 pm, the Assistant Director of Nursing (ADON) stated that oxygen flow rates should be checked every shift. 4. Review of the electronic medical record (EMR) for R4 revealed diagnoses including, but not limited to, acute respiratory failure with hypoxia, unspecified atrial fibrillation, and a personal history of COVID 19. Review of the Quarterly MDS assessment for R4, dated 11/22/2025, revealed that Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. A review of the physician orders for R4 revealed an order dated 6/9/2025 for oxygen at 2 LPM via NC. Observations on 1/6/2026 at 9:43 am and 2:43 pm revealed R4's oxygen flow rate was set at 3 LPM. Observation on 1/7/2026 at 10:11 am revealed R4's oxygen flow rate was set at 3 LPM. In an interview on 1/7/2026 at 10:11 am, LPN FF confirmed that R4's oxygen was set at 3 LPM, and it should be set at 2 LPM. 5. Review of the clinical record for R6 revealed diagnoses including, but not limited to, COPD with acute exacerbation. Review of the Quarterly MDS for R6, dated 10/29/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 10 (indicating moderate cognitive impairment). Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the physician orders for R6 revealed an order dated 10/22/2025 for oxygen at 2 LPM via an NC as needed and as tolerated. Observations on 1/6/2026 at 10:33 am, 2:20 pm, and 1/7/2026 at 8:45 am revealed R6 receiving oxygen via an NC with the flow meter set at 3 LPM. In an interview on 1/6/2026 at 2:20 pm, R6 stated that she did not change her oxygen setting. In a concurrent observation and interview on 1/7/2026 at 11:15 am, LPN FF confirmed that R6's oxygen was set at 3 LPM and was ordered to be set at 2 LPM. In an interview on 1/8/2026 at 3:23 pm, the Director of Nursing (DON) stated that nurses were to check oxygen concentrator flow rates when they go into the room to check on the residents. She further stated that the oxygen flow rate should match the physician's order.

Based on record review, staff interviews, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and investigation, the facility failed to report an allegation of verbal/mental abuse to the State Survey Agency (SSA) for two of 34 sampled residents (R) (R20 and R46). This deficient practice had the potential to place residents at increased risk of abuse. Findings include:Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating revealed the Policy Statement included, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Policy Interpretation and Implementation section included, Reporting Allegations to the Administrator and Authorities: 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility. b.The local/state ombudsman. c. The resident's representative. d. Adult protective services. e. Law enforcement officials. f. The resident's attending physician. g . The facility medical director. 3. Immediately is defined as: a.within two hours of an allegation involving abuse or result in serious bodily injury. b. Within 24 hours of an allegation that does not involve abuse or result in serious bodily injury.1. Review of the Quarterly Minimum Data Set (MDS) for R20, dated 11/7/2025, revealed a Brief Interview for Mental Status (BIMS) of 13, indicating little to no cognitive impairment.Review of a grievance dated 12/15/2025 revealed that R20 stated that CNA MM came into her room to perform patient care, and while changing her brief, CNA MM was very rough, pushing in the resident's shoulder while trying to turn the resident.Record review revealed that the allegation of abuse was not reported to the SSA within the required time-frame.2. Review of the Quarterly MDS assessment for R46, dated 12/1/2025, revealed a Brief Interview for Mental Status (BIMS) of 13, indicating little to no cognitive impairment.Review of a grievance dated 12/15/2025 revealed that R46 stated CNA MM handled the resident very rough and was rude to the resident. The documentation was completed by Social Services. Record review revealed that the allegation of abuse was not reported to the SSA within the required time-frame.In an interview on 1/8/2026 at 1:37 pm, the Social Worker revealed that she took both complaints. She stated R20 complained about being handled roughly during Activities of Daily Living (ADL), and R46 complained about verbal abuse by the same CNA. In an interview on 1/8/2026 at 12:45 pm, the Administrator confirmed the allegations documented on the grievances, stated she had interviewed R46 and R20, and confirmed she did not report the allegations of abuse to the SSA, Ombudsman, police, or medical doctor.

Based on observations, staff interviews, record reviews, and review of the facility's policy titled Soiled Laundry and Bedding Policy, the facility failed to ensure that laundry staff followed infection control processes while performing laundry services. In addition, the facility failed to ensure infection control measures were followed for one of 16 sampled residents (R) (R76) receiving oxygen. These deficient practices had the potential to place residents at risk for infections due to contamination. The census was 80 residents.Findings include:Review of the facility policy titled Soiled Laundry and Bedding Policy revealed that Soiled Laundry and bedding shall be handled, transported, and processed according to best practices for infection prevention and control. The Onsite Laundry Processing section included 1) hand hygiene procedures as well as appropriate personal protective equipment (PPE), includes gloves and gowns are available and used while sorting and handling contaminated linens.1. Observation on 1/7/2026 at 10:09 am revealed that, during the placement of clean linens, the Laundry Aide held clean laundry against her shirt.Observation and interview on 1/7/2026 at 10:33 am revealed that the Laundry Aide was sorting dirty linen without a gown on. She confirmed that she did not have a gown on and did not have access to a gown. She stated she was never informed that she needed to wear a gown while sorting laundry.In a concurrent observation and interview on 1/7/2026 at 11:03 am, the Housekeeping and Laundry Supervisor confirmed that the Laundry Aide was not wearing a gown while sorting linen and confirmed she did not have access to gowns.2. Review of R76's most recent Quarterly Minimum Data Set (MDS) dated [DATE] revealed Section I (Active Diagnosis) revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and acute respiratory distress.Review of the care plan for R76, dated 10/28/2025, revealed that R76 had altered respiratory status and difficulty breathing related to chronic obstructive pulmonary disease.Review of the Physician Orders for R76 revealed an order dated 10/14/2025 for oxygen at two liters per minute (LPM) via nasal cannula (NC) as needed as tolerated per resident every shift. Further review revealed an order dated 10/14/2025 for ipratropium-albuterol inhalation solution 0.5-2.5 milligram (mg)/3 milliliter inhalation orally. Observation on 1/6/2026 at 10:11 am in R76's room revealed that a nebulizer tubing and mask were lying on the nightstand, uncovered and exposed to the environment. Further observation revealed that the oxygen tubing connected to the portable oxygen tank was lying over a rollator.Observation on 1/7/2026 at 7:20 am in R76's room revealed the nebulizer tubing and mask remained on the nightstand, uncovered and exposed to the environment. Further observation revealed that the oxygen tubing connected to the portable oxygen tank was lying over a rollator.In a concurrent interview and observation on 1/8/2026 at 10:32 am, Licensed Practical Nurse (LPN)/Unit Manager II confirmed that R76's nebulizer mask and tubing were lying with the mask down on the nightstand and uncovered. She further confirmed that the portable oxygen tubing was lying uncovered over the rollator.In an interview on 1/8/2026 at 10:42 am, LPN GG stated that nasal canula tubing should be stored in a protective bag when not in use.In an interview on 1/8/2026 at 1:42 pm, the Assistant Director of Nursing (ADON) stated that oxygen and nebulizer tubing should be stored in a protective bag when not in use.

Based on observation, staff interviews, record review, and review of the facility's policy titled [facility name] Care Plans Policy, the facility failed to develop or implement a comprehensive person-centered care plan for four of 34 sampled residents (R) (R21, R46, R76, and R4). This deficient practice had the potential to place R21, R46, R76, and R4 at risk of unmet needs, medical complications, and diminished quality of life.Findings include: Review of the facility's policy titled [facility name] Care Plans Policy revealed that the facility's interdisciplinary team is responsible for the development of resident care plans. 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. Review of the Quarterly Minimum Data Set (MDS) for R21, dated 11/24/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 5 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting, and was dependent for transfers. Section P (Restraints) documented restraints were not used. Review of the care plan for R21, dated 11/24/2025, revealed a focus area that the resident uses bed rails on both sides of the bed in the form of side rails. Interventions included: Complete a bed rail evaluation. Educate the resident, family, and representative of the risk of bed rail use. Bed rail is necessary to treat the following medical condition or symptom as determined by the interdisciplinary team: positioning. The resident is utilizing assist bars on both sides of the bed. Review of the physician orders for R21 revealed no order for bilateral upper and lower bed rails.Observations on 1/6/2026 at 10:37 am and 1/7/2026 at 10:52 am revealed that bilateral upper and lower bed rails were in the up position on the bed. Observation and interview on 1/8/2026 at 8:32 am revealed bilateral upper and lower bed rails in the up position. R21 stated he was not sure why all four rails were up and stated he did not use the bottom rails.In an observation and interview on 1/8/2026 at 10:24 am, Licensed Practical Nurse (LPN) II confirmed that the resident's bed had bilateral upper and lower bed rails in the up position. In an interview on 1/8/2026, the MDS Coordinator on 1/8/2026 confirmed that the care plan for R21 included upper rail assist for positioning and did not include bilateral upper and lower bedrails. 2. Review of the Quarterly MDS for R46, dated 11/25/2025, revealed Section I (Active Diagnosis) revealed diagnoses including chronic diastolic heart failure and generalized anxiety disorder. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the care plan for R46, dated 11/19/2025, revealed that the resident had altered respiratory status and difficulty breathing related to shortness of breath. Interventions included administering supplemental oxygen per ordered. Review of the physician orders for R46 revealed an order dated 12/2/2025 for oxygen at 2 liters per minute (LPM) via [by way of] a nasal cannula (NC) as needed. Observation on 1/6/2026 at 9:35 am revealed that R46 was receiving oxygen, with the concentrator flow rate set between 4 and 4.5 LPM. Observation on 1/7/2026 at 7:22 am revealed that R46 was receiving oxygen, with the concentrator flow rate set at 3.5 LPM. Observation on 1/8/2026 at 8:29 am revealed that R46 was receiving oxygen, and the concentrator was set between 3 and 3.5 LPM. In a concurrent interview and observation on 1/8/2026 at 10:35 am, Licensed Practical Nurse/Unit Manager (LPN/UM) II confirmed that the oxygen flow rate for R46 was set between 4 and 4.5 LPM, the physician's order was for 2 LPM, and the flow rate was not set to the correct level. In an interview on 1/8/2026 at 2:07 pm, the MDS Coordinator confirmed R46's plan of care for supplemental oxygen as per ordered. She confirmed that she was ordered to receive oxygen at 2 LPM via an NC. 3. Review of the Quarterly MDS for R76, dated 10/27/2025, revealed Section I (Active Diagnosis) revealed diagnoses including chronic obstructive pulmonary disease (COPD) and acute respiratory distress. Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. Review of the care plan for R76, dated 10/28/2025, revealed the resident had altered respiratory status and difficulty breathing related to COPD. Interventions included administering supplemental oxygen per ordered. Review of the physician orders for R76 revealed an order dated 10/14/2025 for oxygen at 2 LPM via NC as needed and as tolerated per resident every shift. Observation on 1/6/2026 at 10:11 am revealed that R76 was receiving oxygen, with the concentrator flow rate set to 3 LPM. Observation on 1/7/2026 at 7:20 am revealed that R76 was receiving oxygen, with the concentrator flow rate set at 3.5 LPM. In a concurrent interview and observation on 1/8/2026 at 10:32 am, LPN/UM II confirmed the concentrator flow rate for R76 was set at 3 LPM. She confirmed that the physician's order was for oxygen therapy at 2 LPM. In an interview on 1/8/2026 at 2:07 pm, the MDS Coordinator confirmed R76's plan of care for administering oxygen as ordered. 4. Review of the electronic medical record (EMR) for R4 revealed diagnoses including, but not limited to, acute respiratory failure with hypoxia, unspecified atrial fibrillation, and a personal history of COVID 19. Review of the Quarterly MDS assessment for R4, dated 11/22/2025, revealed that Section O (Special Treatments, Procedures, and Programs) documented that the resident received oxygen while a resident. A review of the care plan for R4 revealed no care area for the use of oxygen. A review of the physician orders for R4 revealed an order dated 6/9/2025 for oxygen at 2 LPM via NC. Observations on 1/6/2026 at 9:43 am and 2:43 pm revealed R4's oxygen flow rate was set at 3 LPM. Observation on 1/7/2026 at 10:11 am revealed R4's oxygen flow rate was set at 3 LPM. In an interview on 1/7/2026 at 10:11 am, LPN FF confirmed that R4's oxygen was set at 3 LPM, and it should be set at 2 LPM. In an interview on 1/8/2026 at 2:10 pm, the MDS Coordinator confirmed that her responsibilities include completing assessments, developing care plans, and conducting restorative assessments. She confirmed there was no care area for oxygen on R4's care plan and acknowledged that it was her error that oxygen therapy had not been added to the resident's care plan and stated that the care plan has since been updated to accurately reflect the resident's oxygen use. Cross-Reference F700 and F695

Based on staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, the facility failed to ensure that allegations of verbal and physical abuse were thoroughly investigated for two of 34 sampled residents (R) (R20 and R46). This deficient practice had the potential to place the residents at increased risk of abuse. Findings include:Review of the facility's undated policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revealed the Policy Statement included, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies . and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The Policy Interpretation and Implementation section included Investigation Allegations: 1. All allegations are thoroughly investigated. The Administrator initiates the investigation. 7. The individual conducting the investigation as a minimum: . l. documents the investigation completely and thoroughly. 1. Review of the Quarterly Minimum Data Set (MDS) for R20, dated 11/7/2025, revealed a Brief Interview for Mental Status (BIMS) of 13, indicating little to no cognitive impairment.Review of the facility's grievances revealed a grievance dated 12/15/2025, documenting that R20 stated that Certified Nurse Aide (CNA) MM came into her room to perform patient care, and while changing her brief, the CNA was very rough, pushing in the resident's shoulder while trying to turn the resident.Review of the progress notes for R20 revealed a medication entry note dated 12/14/2025 at 6:29 pm documenting the resident complained of pain to shoulders, was medicated with pain medication as ordered, and stated the CNA was rough when turning her. Further review of the progress notes revealed an entry dated 12/21/2025 documenting a skin assessment completed by a nurse. Continued review revealed no other documentation related to the allegation reported to the nurse on 12/14/2025. Record review revealed no documented thorough investigation of the allegation of abuse by R20. 2. Review of the Quarterly MDS assessment for R46, dated 12/1/2025, revealed a Brief Interview for Mental Status (BIMS) of 13, indicating little to no cognitive impairment.Review of a grievance dated 12/15/2025 revealed that R46 stated CNA MM handled the resident very rough and was rude to the resident.Record review revealed no documented thorough investigation of the allegation of abuse by R46.In an interview on 1/8/2026 at 11:27 pm, the Human Resources Director revealed that the alleged perpetrator was terminated on 12/16/2025 for resident abuse and is not eligible for rehire.In an interview on 1/8/2026 at 12:45 pm, the Administrator stated that she interviewed R46 and R20 about the allegations of the CNA being verbally abusive and handling them roughly during ADL care. The Administrator stated she terminated the CNA. The Administrator further stated that she did not conduct investigations into the allegations of abuse, except for interviewing R46 and R20, and that she had no documented investigations.

Based on observations, staff interviews, record review, and review of the facility policy titled Medication Administration: General Guidelines, the facility failed to ensure three of 34 sampled residents (R) (R61, R19, and R43) were assessed for medication self-administration before allowing medications at the bedside. This deficient practice has the potential to place R61, R19, and R43 at risk of unsafe medication use and not receiving medication according to the prescriber's order.Findings include: Review of the facility policy titled Medication Administration: General Guidelines, reviewed 7/28/2025, revealed the Procedure section included, .4. Patients/residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. 1. Review of the Electronic Medical Record (EMR) for R61 revealed diagnoses including, but not limited to, legal blindness, as defined in the USA, and combined forms of age-related cataract, unspecified eye Review of the admission Minimum Data Set (MDS), dated [DATE], for R61 revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) of 14 (indicating little to no cognitive impairment). Review of the physician's orders for R61 revealed active orders included GenTeal Tears Severe Day/Night ophthalmic gel 0.4-0.3 percent instill one application in both eyes four times a day for dry eyes, Artificial Tears ophthalmic solution 1 percent instill one drop in both eyes four times a day for prophylaxis, and one drop in both eyes as needed for dry eyes daily. There was no physician's order for medication self-administration or medications at the bedside. Review of the care plan for R61, with a start date of 12/2/2025 and a target date of 12/16/2025, revealed no care plan for self-administration of medication or medication being left at the bedside. Review of the EMR revealed no self-administration of medication assessment indicating that R61 was assessed as capable of medication self-administration. Observation on 1/6/2026 at 10:33 am revealed GenTeal Tears Severe Day/Night ophthalmic gel 0.4-0.3 percent and Artificial Tears ophthalmic solution 1 percent on R61's bedside table. In an interview on 1/6/2026 at 10:33 am, R61 revealed that he used two different eye drops, and he used them in the morning and night. R61 stated that the nurse left the eye drops in the room. In an interview on 1/6 /2026 at 10:39 am, Licensed Practical Nurse (LPN) LL stated the medication should not have been left at the bedside. She stated that they are supposed to watch the residents administer the drops and then return them to the medication cart. In an interview on 1/6/2026 at 10:45 am, LPN DD revealed that she left the eye drops on in R61's room. She stated that she had to go to the bathroom and didn't get back to the room to put them up. 2. Review of the EMR for R19 revealed diagnoses including, but not limited to, unspecified dementia and osteoarthritis. Review of the Quarterly MDS assessment for R19, dated 12/30/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 7 (indicating severe cognitive impairment). Section I (Active Diagnosis) revealed diagnoses of, but not all-inclusive, dementia, anxiety, depression, and osteoarthritis. Review of the care plan for R19, dated 11/24/2025, revealed the resident had an impaired cognitive function and impaired thought processes related to dementia, difficulty making decisions, and long-term memory loss. Further review revealed no care plan for medication self-administration. Review of the physician's orders for R19 revealed an active order for Voltaren Arthritis Pain external gel 1 percent, apply one gram (gm) topically four times a day, related to bilateral primary osteoarthritis of the knee. Further review revealed no physician's order for self-administration of medication. Review of the self-administration assessment, dated 1/6/2026, revealed that R19 was not capable of storing or self-administering medication. Observation on 1/6/2025 at 10:22 am in R19's room revealed a tube of diclofenac (a generic medication for Voltaren) in a basket on the bedside table and a medicine cup with a cream in it. In a concurrent observation and interview on 1/6/2026 at 11:17 am, LPN LL confirmed the cream in a cup and the tube of diclofenac on the bedside tablet. LPN LL stated the resident had a physician's order for the Voltaren gel and was not assessed for medication self-administration. 3. Review of the EMR for R43 revealed diagnoses including, but not limited to, chronic obstructive pulmonary disease (COPD) and obstructive hypertrophic cardiomyopathy. Review of the Quarterly MDS for R43, dated 10/13/2025, revealed Section C (Cognitive Patterns) documented a BIMS score of 12 (indicating moderate cognitive impairment). Section I (Active Diagnosis) revealed diagnoses including, but not limited to, COPD and obstructive hypertrophic cardiomyopathy. Review of the care plan for R43, dated 10/13/2025, revealed that R43 had altered respiratory status/difficulty breathing related to COPD. Interventions included administering medication and puffers as ordered, monitoring for effectiveness and side effects. Review of the physician's orders for R43 revealed an order dated 8/14/2025 for Advair HFA (Hydrofluoroalkane) inhalation aerosol 115-21 microgram (mcg)/actuation (ACT), two puffs inhaled orally two times a day, and swish and spit after use. Further review revealed an order dated 7/25/2025 for azelastine hydrochloride (HCl) nasal solution 0.1 percent, one spray in both nostrils two times a day, and an order dated 9/19/2024 for Proventil HFA inhalation aerosol solution 108 (90 base) mcg/ACT two puffs inhale orally every six hours as needed for shortness of breath. There was no physician's order for medication self-administration. Review of the EMR for R43 revealed no medication self-administration assessment that indicated the resident was capable of self-administering medication. In a concurrent observation and interview on 1/6/2026 at 10:12 am, observation revealed an Advair inhaler, a Proventil inhaler, and an azelastine nasal spray at R43's bedside. R43 stated the nurses left the medications at the bedside in case she needed them. In a concurrent observation and interview on 1/6/2026 at 11:17 am, LPN LL confirmed that she left the two inhalers and nasal sprays at the bedside. She stated that the resident was on the toilet and asked that she leave them on the bedside table. LPN LL stated the medication should not have been left in the resident's room. She stated R43 was not assessed to safely self-administer medications. In an interview on 1/8/2026, the MDS Coordinator confirmed that R61, R19, and R43 were not assessed to self-administer medication.

Based on observations, staff interviews, record review, and review of the facility document titled PICC Lines Procedures, the facility failed to ensure one of one resident (R) (R87) with a peripheral inserted central catheter (PICC) [a long, thin tube inserted into a small arm vein, threaded to a large vein near the heart] from a total sample of 34 residents received care in accordance with professional standards. This deficient practice had the potential to place R87 at increased risk of medical complications. Findings include:A review of the facility's undated document titled PICC Lines Procedures revealed the PICC Maintenance and Care section included, . Aspirate to assess blood flow before every flush and infusion.Review of the physician's orders for R87 revealed an order dated 1/6/2026 for daptomycin (an antibiotic medication used to treat infections) intravenous solution 750 milligrams (mg) every 24 hours. Further review revealed an order dated 1/6/2026 for: Flush single-lumen PICC line to RUE (right upper extremity) using SASH (saline, antibiotic, saline, heparin) protocol one time a day.Observation of medication pass on 1/7/2026 at 9:41 am revealed that Licensed Practical Nurse (LPN) AA applied personal protective equipment, cleaned the PICC line lumen (an individual access point of the PICC line), connected a five milliliter (ml) syringe of 0.9 percent normal saline to the lumen, flushed the line, and did not aspirate (draw back) to check for blood return to verify patency, disconnected the syringe, and connected the daptomycin infusion. In an interview on 1/7/2026 at 9:42 am, LPN AA stated that she flushed the PICC line with normal saline and did not aspirate to check for blood flow before infusing the antibiotic. She stated she should have checked for blood return prior to infusing the antibiotic. She stated that it was standard practice to aspirate to check for blood return.In an interview on 1/7/2026 at 3:12 pm, the Assistant Director of Nursing (ADON) stated that the nurse should draw back blood to check patency of the PICC line before infusing medications. The ADON stated that the SASH protocol was used to maintain the PICC line.In an interview on 1/8/2026 at 3:23 pm, the Director of Nursing (DON) stated that management of PICC lines included enhanced barrier precautions, hand hygiene, and SASH, including blood return to check for patency.

Based on observations, resident and staff interviews, review of the facility's policy titled Side Rail Usage Policy, and review of the facility's protocol titled Restraint- Least Restrictive, the facility failed to ensure that one of 34 sampled residents (R) (R 21) was free from bedrail restraint. This deficient practice had the potential to place R21 at risk of medical complications and a decreased quality of life. Findings include:Review of the facility's undated policy titled Side Rail Usage Policy revealed the Policy section stated, The facility discourages the use of side rails because of the potential safety and dignity issues associated with side rail usage. The Procedure section included, .2. Side rails will only be used if a resident needs the side rail(s) as an enabler to enhance bed mobility. 3. Procedure for side rail usage: a. A physician's order must be obtained for the use of any rail(s). b. The order must include type of rail and location (i.e., resident's right, left, or both). c. The reason for use of the rail(s). 7. The Side Rail Screen Assessment is to be completed on admission and whenever an order is received.Review of the facility's protocol titled Restraint-Least Restrictive, revised 2/2025, revealed Restraints include, but are not limited to: Bed rails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed.Review of the Face Sheet for R21 revealed diagnoses including, but not limited to, history of transient ischemic attacks (TIA), cerebral infarction, muscle weakness, unsteadiness on feet, muscle wasting, lack of coordination, history of falling, and macular degeneration.Review of the Quarterly Minimum Data Set (MDS) for R21, dated 11/24/2025, revealed Section C (Cognitive Patterns) documented a Brief Interview for Mental Status (BIMS) score of 5 (indicating severe cognitive impairment). Section GG (Functional Abilities and Goals) documented that the resident required substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting, and was dependent for transfers. Section P (Restraints) documented restraints were not used. Review of the physician orders for R21 revealed no order for bilateral upper and lower bed rails.Review of the bed rail assessment, dated 6/18/2025, documented bilateral assist rails for positioning.Review of the Assist Bar Consent Form, dated 6/16/2025, for R21 documented that the purpose of assist bars was to assist with repositioning or mobility. Observations on 1/6/2026 at 10:37 am and 1/7/2026 at 10:52 am revealed that bilateral upper and lower bed rails were in the up position on the bed. Observation and interview on 1/8/2026 at 8:32 am revealed bilateral upper and lower bed rails in the up position. R21 stated he was not sure why all four rails were up and stated he did not use the bottom rails.In an observation and interview on 1/8/2026 at 10:24 am, Licensed Practical Nurse (LPN) II confirmed that the resident's bed had bilateral upper and lower bed rails in the up position. She stated the bed should not have all four bed rails in the up position and that bed rail use required a physician's order and a bed rail assessment every six months.In an interview on 1/8/2026 at 10:28 am, Certified Nurse Aide (CNA) HH stated that she had just left R21's room after providing restorative care. She confirmed the bed had bilateral upper and lower bed rails in the up position. She stated that she should have notified the nurse that the resident had four rails up to verify that the resident was supposed to have four rails up.In an interview on 1/8/2026 at 10:45 am, the Director of Nursing (DON) stated the resident should not have bilateral upper and lower bed rails in the up position. She stated that bed rails were used to assist with turning and repositioning. She further stated that bilateral upper and lower bed rails in the up position could be a restraint.

Based on interviews and a review of the In-Service Deficiency Report, the facility failed to ensure an effective training program for all new and existing staff was implemented and maintained. The failure to ensure an effective training program was in place had the potential to impact all of the residents in the facility related to safety, person-centered environment, and the number of adverse events or other resident complications. Findings include: Review of the In-Service Deficiency Report (undated) provided by the facility revealed 19 training topics that should be provided to employees annually. Training topics included: Elopement, EOP (Emergency Operation Plan) Training, Performance Evaluation, Abuse Policy and Procedure (provided quarterly), Communication Training, Fire Safety, Trauma Informed Care, CPR (Cardiopulmonary Resuscitation) Care Verification, Employee Health and Safety, Elope Drill, Tornado Drill, Dementia Management, Disaster Drill based on HVA (Hazard Vulnerability Analysis), Behavior Health Management, Compliance and Ethics Program, QAPI (Quality Assurance Performance Improvement) Program, 90 Day Eval[uation] Nurse Aides, Competency Evaluation, Employee Annual TB (Tuberculosis) test/screening. During an interview on [DATE] at 2:00 PM, the Director of Nursing (DON) said they did not have a formal training program for all staff. She said she would try and provide training on different topics but always had difficulty with staff attendance. She agreed it was important to have a training program for staff because the training could impact resident care and safety. The DON said she had covered topics such as dementia training, wound care, skin care, abuse, elopement, infection control, and proper handwashing. She said she knew that all staff had not attended every training but she was uncertain how to ensure staff did attend and ways to hold staff accountable for attending. She confirmed there was no documentation to show which staff had been trained in which areas and which had not. During an interview on [DATE] at 3:22 PM, the Administrator and the Director of Clinical Operations (DCO) agreed they did not have a formal training program for all existing staff, and the training they provided did not ensure all staff attended. The Administrator said moving forward, they will be holding in-services monthly at multiple times throughout the day to ensure all shifts were able to receive the training and ensure all the necessary topics were covered. The DCO agreed having a training program for all staff was important to ensure they were knowledgeable and could provide quality care to residents.

Based on interviews and observation, the facility failed to ensure three residents (R) (R52, R6, and R285) of 30 sampled residents had enough clean linen, specifically pillowcases, to ensure every resident had enough for all of their pillows. This had the potential for the residents not to have a home-like environment. Findings include: A request was made for a policy related to linens, and was not provided prior to the exit of the survey. 1. Review of R52's Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R52 had an admitted [DATE]. Review of R52's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/05/24, located in the EMR under the MDS tab, revealed R52 had a Brief Interview for Mental Status (BIMS) score of seven out of 15, which indicated R52 was cognitively impaired. During an interview on 10/01/24 at 11:03 AM, Family Member (FM)2 said she saw the facility was out of pillowcases several weeks ago when she came to visit R52. She said she bought pillowcases for R52 and wrote his name all over them. During an observation on 10/02/24 at 9:41 AM, R52 had a pillow on his bed with a pillowcase that belonged to him. It had his name written on the pillowcase. 2. Review of R6's Admission Record, located in the EMR under the Profile tab, revealed R6 had an admitted [DATE]. Review of R6's Quarterly MDS with an ARD of 08/07/24, located in the EMR under the MDS tab, revealed R6 had a BIMS score of 13 out of 15, which indicated R6 was cognitively intact. During an interview on 10/01/24 at 4:15 PM, R6 said quite often they run out of pillowcases, and staff have told her they are out and she would need to wait. She said she would like to have enough pillowcases so all of her pillows could be covered. R6 had two pillows with cases on her bed and three pillows without cases on a chair out of reach. 3. Review of R285's discharge MDS with an ARD of 09/02/24, located in the EMR under the MDS tab, revealed R285 had a BIMS score of two out of 15, which indicated R285 was severely cognitively impaired. During an observation on 10/01/24 at 3:57 PM, R285 was lying in bed with a pillow under his head, without a pillowcase. During an interview on 10/01/24 at 4:01 PM, the Director of Nursing (DON) confirmed there were no pillowcases in the Station Two or Station Three linen closet, which were the only two places pillowcases were stored. The DON said all residents should have pillows in their rooms, and every pillow should have a pillowcase. The DON confirmed R285 did not have a pillowcase on the pillow he was sleeping on and should have one. During an interview on 10/02/24 at 9:31 AM, Unit Manager (UM) 1 confirmed there was one pillowcase in the Station Two linen closet and no pillowcases in the Station Three linen closet. She said she would always expect to see a pillowcase on all pillows and said, If a resident has a pillow, there should be a case on it. During an interview on 10/03/24 at 9:35 AM, the Housekeeping Supervisor (HSKS) revealed residents were using more pillows, but she had not been ordering more pillowcases. She said if a resident had more pillows, there should be more pillowcases. She said she ordered pillowcases at least once a month. She agreed it was a problem if residents did not have enough pillowcases. During an interview on 10/03/24 at 3:22 PM, the Administrator agreed that every resident should have enough pillowcases so every pillow they have on their bed has a pillowcase.

Based on interviews and record review, the facility failed to provide one of three residents (R) (R134) reviewed for Notice of Medicare Non-Coverage (NOMNC) of 30 sampled residents, a NOMNC 48 hours before the end of a Medicare-covered Part A stay. This had the potential for the resident to not have the opportunity to appeal the decision to end the Medicare Part A stay. Findings include: Review of the Admission Record, located in the Electronic Medical Record (EMR) under the Profile tab, revealed R134 had an admitted [DATE] and a readmitted [DATE]. The resident discharged from the facility on 06/16/24. Review of the NOMNC provided by the facility, revealed R134's Medicare services would end on 06/16/24. The NOMNC revealed R134 was notified of his last covered day on 06/16/24 when he signed the document. During an interview on 10/01/24 at 9:32 AM, the Social Worker (SW) said she would always have the resident or their family member sign the NOMNC within 48 hours of their last covered day. She confirmed she did not issue R134's NOMNC until 06/16/24, which was his last covered day. She confirmed the NOMNC should have been issued on 06/14/24. During an interview on 10/03/24 at 3:30 PM, the Administrator agreed the NOMNC should have been issued timely, which would have been two days in advance.

Based on interviews and record review, the facility failed to ensure two residents (R) (R24 and R78) and/or the resident representative (RR) of five residents reviewed for unnecessary medications out of a total sample of 30 residents was informed of the risk and benefits of physician ordered antipsychotic medications. This failure placed the resident and/or representative at risk of not knowing the risks and benefits of the use of medications. Finding include: 1. Review of R24's Admission Record dated 10/03/24, located in the resident's electronic medical record (EMR) under the Resident Summary tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease. Review of R24's Physician Order dated 08/02/23, located in the Orders tab of the EMR revealed, Depakote [to treat certain psychiatric conditions and seizures] 125 mg [milligrams] two times a day and Risperdal [to treat certain mental/mood disorders] 0.5 mg [milligrams] two times a day. Review of R24's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/12/24 located in the resident's EMR under the MDS tab revealed the resident did not have a Brief Interview for Mental Status (BIMS) and was rarely/never understood and was administered an antipsychotic medication on a routine basis during the observation period. Review of the Resident Documents tab and the Nursing Progress Notes tab of the EMR did not document that R24 or her RR was informed of the risks and benefits prior to initiating a new Physician Order for the Risperdal or Depakote. During an interview on 10/02/24 at 1:50 PM, R24's Power of Attorney (POA), Family Member (FM)1 was asked if she was aware of the Physician Order for the Risperdal and why R24 was being administered the medication. POA stated R24 had been placed on a medication that was causing her to be very zombie-like. The POA stated they had a care plan meeting at the facility in July 2024 and asked for all mood-altering medications to be stopped, and they were under the impression that R24 wasn't on anything currently. During an interview on 10/02/24 at 2:55 PM, The Director of Nursing (DON), DON stated they did not get consents due to having residents sign a consent to treat upon admission. DON stated their staff were going over risks and benefits but were failing to document them. The DON further confirmed R24's Risperdal was discontinued, as discussed in the care plan meeting in July 2024. 35690 2. Review of the Admission Record, located in the EMR under the Profile tab, revealed R78 had an admitted [DATE]. R78 had a diagnosis of Huntington's Disease. There was no diagnosis listed for depression. Review of R78's admission MDS with an ARD of 07/26/24, located in the EMR under the MDS tab, revealed R78 was unable to be interviewed and was severely impaired cognitively. Staff observed the resident to appear to be feeling down. R78 did not have behaviors. Review of R78's Medication Administration Record (MAR) located in the EMR under the Orders tab, revealed R78 received one tablet, 15 mg (milligrams) of Mirtazapine (an anti-depressant) with a start date of 07/23/24. R78 also received one tablet, 50 mg of Trazodone (an anti-depressant) daily for sleep, with a start date of 09/19/24. Review of R78's EMR revealed no evidence the resident's RR was notified the resident was starting two new medications for depression or that the risks and benefits were explained to the RP. During an interview on 10/02/24 at 11:00 AM, the DON said they did not provide the resident or family information about the risks and benefits for the use of psychotropics. She said the only signed form they had for residents was a Consent to Treat form that is signed upon admission. During an interview on 10/03/24 at 9:57 AM, the MDS Coordinator (MDSC) said they did not discuss with the family the risks and benefits of any psychotropic medication for the resident. She said nursing will only notify the family that the medication has been started. During an interview on 10/03/24 at 1:42 PM, Family Member (FM) 3 said she was aware the physician was going to start a medication for sleep for R78. She said a nurse called and told her they would be starting a medication for R78 to help her sleep, but she did not know any other details. FM3 said she was not made aware of any other psychotropic medications that R78 had started. She said she would have liked to have been informed of both medications and educated on the risks and benefits. A request for a policy related to psychotropic medications and consents was not provided prior to the exit of the survey.

Based on observations, staff interviews, and a review of the facility's policies titled Food Storage and Procurement, and Diet/Food Handling, the facility failed to ensure that food items in the two refrigerators and two freezers were properly labeled, dated, and securely wrap opened food items and discarded foods when expired; failed to properly use the three-compartment sink to properly sanitize dishware. Additionally, the facility failed to thaw frozen meat and fish properly to prevent bacterial growth; failed to store stacked pans free from wet nesting to prevent bacterial growth; failed to have soap in the soap dispenser and paper towels in the towel dispenser so staff could properly wash and dry hands; failed to clean the can opener and free from debris buildup to prevent cross contamination; and failed to maintain a clean and sanitary kitchen. The facility census was 86, with 83 residents consuming an oral diet. These failures had the potential to support bacterial growth associated with foodborne illness. Findings include: Review of the policy titled Food Storage and Procurement reviewed [DATE], Purpose: To ensure wholesome food is purchased and served. To ensure food purchasing practices that support food safety are followed. To maintain compliance with Federal, State, and Local regulations governing food safety. Review of the policy titled Diet/Food Handling revised [DATE], Purpose: To provide guidelines for the safe preparation, handling, and storage of perishable food and proper environmental cleaning. 13. Staff should have access to proper hand washing facilities with available soap, hot water, and disposable towels. Observations during an initial tour of the kitchen on [DATE] at 7:50 a.m. revealed: No soap in the soap dispenser or paper towels in the towel dispenser so staff could properly wash and dry hands. The sink was noted with grime buildup. Observation of freezer #1 revealed: A bag of open frozen tater tots was not labeled with its content, not sealed, had no expiration date, and had no open date or use-by date on the bag. A bag of frozen biscuits was not labeled with its content, not sealed, had no expiration date, and no open date or use-by date on the bag. A bag of open frozen French fries was not labeled with its content, not sealed, had no expiration date, and no open date or use-by date on the bag. A bag of open frozen cake bites was not labeled with its content, not sealed, with no expiration date, and no open date or use-by date on the bag. Packages of unopened frozen rolls were not labeled with their content, expiration date, or use-by date on the bag. Observations of freezer #2 revealed: Two bags of open ham hocks were not labeled with their content, not sealed, had no expiration date, and no open date or use-by date on the bag. A bag of open frozen meat (not sure of type) was not labeled with its content, not sealed, with no expiration date, and no open date or use-by date on the bag. A bag of open and sealed frozen chicken fingers was not labeled with its content, no expiration date, and no open date or use-by date on the bag. A bag of open frozen and sealed beans/peas was not labeled with its content, no expiration date, and no open date or use-by date on the bag. A bag of open and sealed frozen chicken was not labeled with its content, no expiration date, and no open date or use-by date on the bag. A box of open frozen fish fillets was not labeled with its content, not sealed, with no expiration date, and no open date or use-by date on the bag. Observation of refrigerator #1 revealed: A pitcher of brown liquid (tea) with plastic wrap over the top not dated with use by date or content. A squeeze bottle of grape jelly and a bottle of ranch dressing with use-by dates of ,d+[DATE] Observations of refrigerator #2 revealed: Already prepared food was in a container (soup/stew), covered with plastic wrap, and not labeled with its content, preparation date, or use-by date. Already prepared food was in a container (macaroni and cheese) and was covered with plastic wrap, was not labeled with its content, preparation date, or use-by date. A bag of sausage (kielbasa) was not labeled with its content, expiration date, or use-by date on the bag. Observations of the kitchen area revealed: The air vent above the washing machine was rusty with peeling paint. The air vent near the kitchen/dining room door had dust buildup. The manual industrial can opener was dirty with dark black grime build-up. Pots and pans were not nested upside down. The preparation table behind the oven and the two tables next to the steam table were noted with sticky dark black grime built up on the lower shelves. A hole in the wall next to the window, and dust and grime build up on the windowsill. The floors had visible dirt with stains throughout the kitchen and in front of the freezers. Observation of the dining room revealed a coffee machine with brown grime built up on it. The coffee machine was not in use at this time; waiting for the machine to be removed. Observation of the three-compartment sink revealed that the sanitizer sink is not used due to a drain problem. Observation of the vegetable/meat sink revealed meat in the vegetable side of the double sink in sealed bags being defrosted without any running water over the meat. Meat appeared defrosted. The meat was thrown away and not used. Observations on [DATE] at 8:32 a.m. revealed: No soap in the soap dispenser or paper towels in the towel dispenser so staff could properly wash and dry hands. The sink was noted with grime buildup. Observation of the vegetable/meat sink revealed fish in the vegetable side of the double sink in a metal pan with water in it, being defrosted without any running water over the fish. The fish appeared defrosted. The fish was thrown away and not used. Observations of the kitchen area revealed: The air vent above the washing machine was rusty with peeling paint. The air vent near the kitchen/dining room door had dust buildup. The manual industrial can opener was dirty with dark black grime build up. Pots and pans were not nested upside down. The preparation table behind the oven and the two tables next to the steam table were noted with sticky dark black grime built up on the lower shelves. A hole in the wall next to the window, and dust and grime build up on the windowsill. The floors had visible dirt with stains throughout the kitchen and in front of the freezers. Observation of the dining room revealed a coffee machine with brown grime built up on it. The coffee machine was not in use at this time; waiting for the machine to be removed. Observation of the three-compartment sink revealed that the sanitizer sink is not used due to a drain problem. The Registered Dietitian (RD) conducted a Sanitation Review dated [DATE] revealed: 54 out of 67=Score of 81% 85% or better is expected. A lower score requires a Performance Improvement Plan Areas of concern identified included: Clean window scale by the coffee pot Boxes off floor Clean both freezers Three-compartment sinks must be fixed, and no sanitizer. The dining room needs a good cleaning, and all equipment not used must go. Doors on dumpsters must be kept closed. Interview on [DATE] at 8:18 a.m. with the Dietary Manager (DM) revealed she is in class to get certified. She indicated that the RD was coming in two times a month. She was currently on medical leave. She is available by phone and e-mail. The DM indicated that all foods should be labeled with an opened date and a used by date. The kitchen staff are to fill out the sticker and put it on the food when food is opened, or a label falls off. She indicated that all foods should be sealed when opened. Interview on [DATE] at 8:08 a.m. with the DM revealed that the coffee servers in the dining room area are not used, and she has asked the Maintenance Supervisor to remove them. The DM indicated that food should be defrosted under running cold water, not left in a sink without running water, and use the sink dedicated to meat. Interview on [DATE] at 8:08 a.m. with the Cook HH revealed that she had running water on the fish but had recently turned it off. A follow-up interview on [DATE] at 9:25 a.m. with the DM and Cook DD indicated they do not follow a menu for preparing the pureed foods. A phone interview on [DATE] at 1:55 p.m. with the RD revealed she recommended cleaning the kitchen more thoroughly. Interview and observation of the kitchen on [DATE] at 9:00 a.m. with the Administrator revealed: A tour of the kitchen's overall sanitation and cleanliness revealed grime buildup in several areas identified above, and he indicated he would expect the kitchen to be clean and sanitized; he would expect the staff to follow the proper procedure and policy and label all foods accordingly; he would expect the staff to report concerns and follow-up on them; he indicated the need to replace some of the older preparation tables that are stained with grime buildup. He was unaware of the three-compartment sink, and sanitation sink, not functioning properly. The Administrator indicated he gets the reports from the RD occasionally but does not recall the one dated on [DATE].

Based on observation, staff interview, and review of the facility's policy titled Storage of Personal Care Items,, Laundry Dryer Vent Cleaning Policy, and the Operation/Maintenance Manual the facility failed to ensure resident basins, urinals, and bedpans were labeled and covered for eight of 53 rooms. In adddition, the facility failed to clean the lint filter and cylinder exhaust tube according to the manufacturer's instructions for use (IFU) to prevent potential fire hazards; failed to clean the laundry eyewash station clean and free of dirty and debris; failed to properly store personal care items in 8 rooms. Findings include: 1. A review of the facility policy titled Storage of Personal Care Items, reviewed 1/2022, revealed residents' personal care items, such as wash basins, urinals, and bedpans, would be labeled with the resident's name, and stored in plastic bags. Observation on 7/14/2023 at 9:02 a.m. of the bathroom shared by rooms 119 (R#63 and R#33) and 117 (R#75) revealed one bedpan and one basin sitting on the floor in the bathroom. Neither receptacle was covered or labeled. Observation on 7/14/2023 at 9:32 a.m. of the bathroom shared by rooms 111 (R#16) and 113 (R#12 and R#20) revealed one urinal in the bathroom. The urinal was unlabeled. Observation on 7/14/2023 at 9:40 a.m. of the bathroom shared by room [ROOM NUMBER] (R#57 and R#8) and room [ROOM NUMBER] (R#28 and R#11) revealed three basins sitting on the floor in the bathroom. All basins were uncovered and unlabeled. Observation on 7/14/2023 at 10:43 a.m. of the bathroom shared by room [ROOM NUMBER] (R#37) and room [ROOM NUMBER] (R#74 and R#22) revealed one basin sitting on the floor in the bathroom. The basin was uncovered and unlabeled. Interview on 7/14/2023 at 9:47 a.m. with the Licensed Practical Nurse (LPN) BB revealed that all basins, urinals, and bedpans were supposed to be labeled with the resident's names and covered. The LPN BB acknowledged that the items were unlabeled and uncovered, and she could not identify which item belonged to which resident. She stated that all the items would be thrown away and replaced with labeled and covered items. Interview on 7/14/2023 at 10:43 a.m. with the Certified Nursing Assistant (CNA) CC revealed she could not determine who the basin belonged to in rooms [ROOM NUMBERS]. She stated that all basins were supposed to be labeled and covered. CNA CC indicated she would throw the basin away. Interview on 7/15/2023 at 7:48 a.m. with the Director of Nursing (DON) revealed she expected staff to label all resident basins, bedpans, and urinals and to cover them when stored. She added that the items should not be stored directly on the floor in the bathrooms. 38997 2. Review of the policy titled Laundry Dyer Vent Cleaning policy dated 1/15/2023 revealed: Environmental staff-laundry staff will check and clean out the dryer vent after each load. Laundry staff will notify maintenance if there are other areas that need cleaning or minor maintenance. Review of the Tumble Dryers __ Operation Maintenance manual for dryer number one. Safety Information: This tumble dryer must not be activated without lint screen filter. When you perceive a gas odor, immediately shut off the gas supply and ventilate the room. Do not power on electrical appliances and do not pull electrical switches. Do not use matches or lighters. Do not use a phone in the building. Warn the installer, and if so desired, the gas company, as soon as possible. To avoid fire and explosion, keep surrounding areas free of flammable and combustible products. Regularly clean the cylinder and exhaust tube should be cleaned periodically by competent maintenance personnel. Daily remove debris from lint screen filter and inside of filter compartment. Always clean the lint filter daily. Keep area around the exhaust opening and adjacent surrounding area free from the accumulation of lint, dust, and dirt. The interior of the tumble page dryer and the exhaust duct should be cleaned periodically by qualified service personnel (page 6). Maintenance: Daily 2. End of day: Clean lint filter to maintain proper airflow and avoid overheating. Monthly 3. Remove lint filter and thoroughly vacuum exhaust duct. 5. Wash lint screen with hot water and mild detergent to remove fabric softener residue {sic}. Yearly 3. Remove any accumulated lint or debris from thermistor, cabinet high limit thermostat, stove high limit thermostat(s), including perforated cover, if present. Lint buildup will act as an insulator, causing machine to overheat. 4. Remove any accumulated lint or debris from drive and blower motors. 5. Remove any accumulated lint or debris from burner tubes and orifice area. Remove burner tubes and clean using water and a brush (page 20). The facility did not provide an operation manual for dyer number two. Observation on 7/15/2023 at 1:31 p.m. of the facility's two industrial dryers. When standing facing the dryers: dryer one to the left: an observation of the lint trap revealed the floor of the lint trap was clean and free of lint. The dryer has a large lint filter that was broken and had a copious amount of lint. dryer two to the right: an observation of the lint trap revealed the floor of the lint trap was clean and free of lint. The lint filter and the upper inside of the wall had a copious amount of lint. The eye wash station located across from the dryers area is covered with dust and dirt. Observation on 7/16/2023 at 8:30 a.m. of the facility's two industrial dryers. When standing facing the dryers: Dryer one to the left: an observation of the lint trap revealed the floor of the lint trap was clean and free of lint. The dryer has a large lint filter that was broken and had a copious amount of lint. Dryer two to the right: an observation of the lint trap revealed the floor of the lint trap was clean and free of lint. The lint filter and the upper inside of the wall had a copious amount of lint. An observation of the cylinder exhaust tubes (outside) revealed a large amount of lint. The eye wash station located across from the dryers area is covered with dust and dirt. Interview on 7/15/2023 at 1:30 p.m. with the Laundry Aide ZZ stated after each load of clothes has completed the drying process the lint trap floors are cleaned. She stated the maintenance director is responsible for cleaning the filters. Interview on 7/16/2023 at 8:31 a.m. with the Laundry Aide ZZ confirmed that the lint trap and the lint filters have large amount of lint. She stated she is aware not keeping the dyers free from lint can cause a fire. Laundry Aide ZZ stated she can only clean the lint that is on the lint trap floor of the dryer. She stated she asked the Maintenance Director (MD) on multiple occasions to clean the lint filters and clean out the cylinder exhaust tubes. She has requested several times for the lint filters and cylinder exhaust tubes to be cleaned. The MD tells her he is only one person and is too busy. The Laundry Aide confirmed that the eyewash station is covered with dust and dirt. She stated she wouldn't feel safe using the eyewash station to rinse her eyes. Interview and observation on 7/16/2023 at 9:17 a.m. with the Administrator and Director of Nursing (DON) of the laundry area. The Administrator confirmed that both dryer lint traps and filters needed to be cleaned. He also confirmed the broken lint filter on dryer number one. The Administrator stated the lint traps should be cleaned after each use. He stated it is the responsibility of the MD to make sure the lint filters and cylinder exhaust tubes are cleaned and in working order. He stated he understands that not cleaning the lint traps and lint filters are a fire hazard. The Administrator stated he will ensure that the lint trap and filters are cleaned regularly. He also confirmed the eye wash station located across from the dryers area is covered with dust and dirt. He stated he was sure it was coming from the dust blowing from the dryers.

Based on observation, staff interviews, and record review, the facility failed to ensure that dietary staff followed recipes for preparing pureed foods to avoid compromising the nutritive value, flavor, or appearance. This affected six of 83 residents receiving an oral diet. Findings include: Observation on 7/15/2023 at 9:25 a.m. of Dietary Cook HH preparing puree black-eyed peas revealed that no recipes were seen or used as a reference during preparation. Dietary cook HH started with hot cooked black-eyed peas by placing 14 four-ounce (oz) scoops in the food blender. Using an unlabeled scoop, the cook then added one scoop of food thickener and an unmeasured amount of liquid from the pot of cooked peas and pureed until well blended. The Dietary Cook HH placed the pureed black-eyed peas in a steam table pan. When placed in the pan, the pureed black-eyed peas had a thick like consistency. Next, the Dietary Cook HH pureed cooked beef patties in a brown gravy liquid by placing 14 beef patties along with an unmeasured amount of the brown gravy liquid and one unlabeled scoop of thickener into the food blender and pureed until well blended. She then added an unmeasured amount of the brown gravy liquid to thin out the mixture. The cook placed the pureed beef mixture in a steam table pan. When placed in the pan, the pureed beef mixture had a thick like consistency. Interview on 7/15/2023 at 9:25 a.m. with the Dietary Manager (DM) and the Dietary Cook HH indicated they do not follow a menu for preparing the pureed foods. They also do not have a policy for preparing pureed food.

Based on observations, staff interviews, and a review of the facility's policies titled Cleaning of Residents Rooms, and Cleaning and Disinfection of Environmental Surfaces, the facility failed to maintain a safe, clean, sanitary, homelike environment related to a heavy build-up of dust on ceiling vent covers and two wheelchairs, unclean privacy curtains, broken and dirty Hoyer lifts (5), broken light fixture, and disrepair of handrail and exit door for 14 residents' rooms ( Rooms 115, 119, 121, 122, 123, 124, 125, 127, 129, 131, 135, and 139) and one hallway (200 Hall). Findings include: 1. Observation on 7/14/2023 at 8:30 a.m. and 7/15/2023 at 8:30 a.m. revealed beside the conference room, the door to the outside was heavily damaged and slightly ajar. A mice and swarm of bees were noted in the area outside the door which was unused and led to the courtyard. The area was grown up with standing water, old wood and screens, toilets, and empty garbage cans. Several gnats noted flying around in the conference room. Observation and interview on 7/15/2023 at 5:30 p.m. with the Maintenance Director revealed the door had been like this for three years. He placed plastic around the door to seal it off. Further interview on 7/16/2023 at 10:00 a.m. revealed they have a plan to fix the door and outside area. 2. Observations on 7/14/2023 at 1:01 p.m., 7/15/2023 at 9:27 a.m., and 07/16/2023 at 2:30 p.m. revealed a small handrail along the hallway outside of room [ROOM NUMBER] was broken with pieces of the outside missing. Observation and interview with Licensed Practical Nurse (LPN) SS on 7/16/2023 at 2:27 p.m. revealed a book at the nursing station where staff document repairs needed and signature of Maintenance Director when addressed or repaired. She stated staff will call him directly with repairs that are needed right away. Interview with the Administrator on 7/16/2023 at 3:00 p.m. revealed the facility has been addressing environmental concerns and corporate is involved. He stated they have replaced the roof, air conditioning system, and plumbing and plan to continue making repairs. He stated he has obtained help to assist the Maintenance Director because the job is overwhelming and because the building is old, there's always something every day that needs maintenance. 38997 2. Review of the policy titled Cleaning of Residents Rooms dated 7/2022 indicated: The purpose of this procedure is to provide guidelines for cleaning and disinfecting residents' rooms. General Guidelines 4. Walls. blinds. and window curtains in resident areas will be cleaned when these surfaces arc visibly contaminated or soiled. Resident Room Cleaning: 7. Clean personal use items (e.g., lights, phones, call bells, bedrails, etc.) with disinfectant solution at least twice weekly. 11. Clean curtains, window blinds, and walls when they are visibly soiled or dusty. Review of the policy titled Cleaning and Disinfection of Environmental Surfaces and Equipment dated 7/2022 indicated: Policy Statement: Environmental surfaces will be cleaned and disinfected according to current CDC recommendations for disinfection of healthcare facilities and the OSHA Bloodborne Pathogens Standard. Policy Interpretation and Implementation: 17. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 18. Environmental surfaces will be disinfected (or cleaned) on a regular basis (e.g., daily, three times per week) and when surfaces are visibly soiled. 19. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. An observation on 7/15/2023 at 9:41 a.m. of room [ROOM NUMBER] occupied by two residents. The privacy curtains between beds A and B have tan and yellow stains on the lower part. The upper part of the privacy curtains had holes. Bed A & B have a tabletop fan on the nightstand with a thick amount of light gray colored debris on the fan blades-an observation of a brown substance splatter on the wall under the window. An observation on 7/15/2023 at 10:18 a.m. of the facility Hoyer Lifts, sit to stand lifts, and wheelchair scales, revealed the following: a. Hoyer lift Number #1 located across from the 200-hall nursing station. The mast, foot plate, base leg, and wheels (four) was covered with dirt and debris. b. Hoyer lift #2 located across from the conference room. The mast, foot plate, base leg, and wheels (four) was covered with dirt and debris. The Hoyer lift also had rust spots on the base leg. c. Hoyer Lift #3 located on the front right side of the 200-hall dining room. The motor, mast, foot plate, base leg, and wheels (four) was covered with dirt and debris. d. Hoyer lift #4 located across from the 200-hall nursing station. The foot plate, base leg, and wheels (four) was covered with dirt and debris. e. Hoyer Lift #5 located in the back of the 200-hall nursing dining room. The mast, foot plate, base leg, and wheels (four) was covered with dirt and debris. f. Hoyer Lift #6 is located in the back of the 200-hall dining room. The mast, foot plate, base leg, and wheels (four) were covered with dirt and debris. g. Two wheelchair scales are located on the right and left of the 200-hall dining room. The platform of the scales was covered with dirt and debris. h. The Sit-To-Stand Lift #1 is in the back of the 200-hall dining room. The foot plate of the lift was covered with food crumbs; the base legs were covered with dirt and debris. i. The Sit-To-Stand Lift #2 located across from the smoking area. The foot plate and base legs are covered with dirt and debris. An interview on 7/15/2023 at 9:50 a.m. with Certified Nursing Assistant (CNA) NN stated that the facility has 5 Hoyer Lifts. The CNA stated that the three lifts located at the back of the dining room were not working. He stated that he does not place a lock out sign on the lifts to alert the staff that they are not working. He stated that he verbally alerts the staff when the lifts are not working. When asked what happens when he is not working, the CNA stated he is always working. The CNA confirmed that the lifts were dirty. The CNA stated he does not know who is responsible for cleaning the lifts. An interview and observation on 7/16/2023 at 9:17 a.m. with the Director of Nursing (DON) confirmed that the facility has six Hoyer lifts and two Sit-To-Stand lifts. The DON stated she was not aware that three lifts were not working. The DON stated that the equipment is rented, and the company repairs the lifts. The DON confirmed that the above equipment was dirty, and room [ROOM NUMBER] curtains, table fan, and wall were also dirty. She stated she would have room [ROOM NUMBER] and the lifts and scales cleaned. She also stated she would find out what lifts are not working and have them serviced. 39844 3. Observations on 7/14/2023 at 10:00 a.m. and 4:20 p.m., 7/15/2023 at 7:58 a.m. and 7/16/23 at 10:00 a.m. of room [ROOM NUMBER] revealed a loose night light fixture cover on the wall near resident in 309A. Observation and interview on 7/16/2023 at 10:00 a.m. with the Administrator and Maintenance Supervisor verified the loose light fixture cover on the wall. The Maintenance Supervisor has fixed the night light cover in the past. He indicated it gets caught on the bed when they lower it, and the bed is kept against the wall. He indicated he was not aware of the problem. They usually use verbal communication or electronic communication on an app to report problems. He checks the electronic report daily. 46691 4. Observations on 7/14/2023 at 10:00 a.m. and 4:20 p.m., 7/15/2023 at 7:58 a.m., and 7/16/2023 at 10:00 a.m. of room [ROOM NUMBER] revealed a loose night light fixture cover on the wall near resident in 309A. Observation and interview on 7/16/2023 at 10:00 a.m. with Administrator and Maintenance Supervisor verified the loose light fixture cover on the wall. The Maintenance Supervisor has fixed the night light cover in the past. He indicated it gets caught on the bed when they lower it, and the bed is kept against the wall. He indicated he was not aware of the problem. They usually use verbal communication or electronic communication on an app to report problems. He checks the electronic report daily.

Based on observations and staff interviews, the facility failed to ensure a reasonable accommodation of need by keeping the call within reach of residents when in their room to call for staff assistance for three of sixteen Residents (R) (#41, #4, #14) in the 300 Hall. Observations on 7/14/2023 at 11:28 a.m. and 4:25 p.m., 7/15/2023 at 7:45 a.m., and 7/16/2023 at 10:00 a.m. of room [ROOM NUMBER]A R#4 and 311B R#14 revealed call lights for both bed A and B were wrapped around the call box and not in reach of the resident. Both residents were sitting up in a chair beside the bed during observations or in the bed. Observations on 7/14/2023 at 11:36 a.m. and 4:35 p.m., 7/15/2023 at 7:55 a.m., and 7/16/2023 at 10:00 a.m. of room [ROOM NUMBER]B R#41 revealed call light for bed B was on the floor and not in reach of the resident. The resident was asleep in bed during observations. Interview on 7/16/2023 at 9:40 a.m. with Certified Nursing Assistant (CNA) GG revealed she is responsible for keeping a call light within reach of all residents. She will check them each time she goes into a resident's room. Interview on 7/16/2023 at 9:42 a.m. with CNA JJ revealed that she checks the call lights each time she enters a resident's room. She indicated that the residents in room [ROOM NUMBER] would move them and put them on the call box or on the floor. Observation and interview on 7/16/2023 at 10:00 a.m. with the Administrator and Maintenance Supervisor revealed that all lights were not within reach of the residents identified above. The Administrator indicated they should be kept within reach according to regulations. The Administrator indicated that they do not have a call light policy.

Based on observation, staff and resident interview, record review, and review of the facility's policy titled Foley Catheter Care, the facility failed to maintain dignity by ensuring a dignity bag was provided for one of six residents (R) (R#16) who had an indwelling urinary catheter. This failure had the potential to diminish the resident's quality of life in an environment that promotes the maintenance or enhancement of each resident's quality of life. Findings include: A review of the facility policy titled Foley Catheter Care, reviewed 1/2022, revealed catheter bags would be placed in a dignity bag or cove. A review of the CNA Mandatory Clinical Meeting Form dated 11/14/2023 revealed that the facility provided training to ensure that staff placed Foley catheter bags in a privacy bag. A review of the most recent Minimum Data Set (MDS) Quarterly Assessment for R#16 dated 5/22/2023 revealed in section C-Cognition that R#16 had a documented Brief Interview for Mental Status (BIMS) score of 15. Section H-Bowel & Bladder revealed R#16 had an indwelling catheter and was always incontinent of bowel. Observation on 7/14/2023 at 8:50 a.m. revealed that R#16 had a Foley catheter, and the bag was not covered with a dignity bag. The Foley bag had approximately 500 milliliters (mL) of yellow urine visible from the hallway. Observation on 7/14/2023 at 1:17 p.m. revealed R#16 Foley catheter bag remained uncovered. The Foley bag had approximately 250 mL of yellow urine visible from the hallway. Observation on 7/15/2023 at 7:18 a.m. revealed R#16 Foley catheter bag remained uncovered. The Foley bag had approximately 400 mL of yellow urine visible from the hallway. Interview on 7/14/2023 at 8:55 a.m. with R#16 revealed she liked living in the facility. She added that the staff was very nice, and she never had any issues related to care. The resident stated that the staff cleaned her peri area around the Foley catheter daily, and the staff was good about ensuring it was clean. She added that the staff emptied the bag in a timely manner. Interview on 7/15/2023 at 7:23 a.m. with Licensed Practical Nurse (LPN) AA revealed R#16's Foley bag should be covered with a dignity bag, and the LPN acknowledged the Foley bag was not covered and visible from the hallway. Interview on 7/15/2023 at 7:46 a.m. with the Director of Nursing (DON) revealed that she expected all resident Foley bags to be covered with a dignity cover bag.

Based on record review, review of the facility policy titled Quality Assurance and Performance Improvement (QAPI) dated [DATE] and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, and implemented corrective action plans for residents with pressure ulcers, surgical wounds and weight loss. The QAA committee also failed to identify that their established policies for Skin Assessment Guidelines, Skin Care Guidelines, Change of Condition and Nutrition: Weight Monitoring Program were not being fully operationalized, and therefore failed to implement corrective actions to address the problems. The facility census was 76. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director (SW) was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order for [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains ongoing. Findings include: Review of the facility's Quality Assurance and Performance Improvement (QAPI) policy with a date of [DATE] revealed that the QAPI program was an on-going, comprehensive program that addressed all systems of care and management practices, and included clinical care, quality of life and resident choice for excellence in the delivery of health care. The program included participation from all departments. The QAPI committee reported to the Governing Body and was responsible for meeting at a minimum at least quarterly, monthly or more often if needed; coordinated and evaluated QAPI program activities; developed and implemented appropriate plans of action to identify and correct quality deficiencies; regularly reviewed and analyzed data to identify and follow-up on areas of concern and/or opportunities for improvement; acted on available date to make improvements; and determined areas for Performance Improvement Plans (PIPs) and Plan-Do-Study-Act (PDSA) rapid cycle improvement projects. The facility used a Root Cause Analysis (RCA) Worksheet to analyze information and summarize the root cause of quality deficiencies so that actions could be developed to correct them. After implementing the actions, the QAPI committee would track performance in order to verify that improvements were realized and sustained. Review of the Performance Improvement Committee Meeting Minutes dated [DATE] revealed that the Medical Director, Director of Nursing (DON) Social Worker (SW), Minimum Data Set (MDS) Coordinator and seven additional department heads were present; however, the Administrator had not signed the Attendees List. The committee discussed multiple issues including care plans and skin assessments. However, review of the information provided by the Social Services Director (SW) revealed that the minutes did not include a Performance Improvement Plan (PIP) that addressed specific issues related to skin assessments and care plans, corrective measures/interventions that were developed, expected outcomes, completion date or designation of staff who was responsible for monitoring the effectiveness of the interventions. Furthermore, there was no indication that the QAPI committee identified and developed corrective measures to address staff failure to provide pressure ulcer and wound treatments as ordered by the Physician for four residents (R#1, 2, 3, 4); staff failure to identify and address a significant weight loss for R#1; staff failure to notify the Vascular Surgeon of the deterioration of the surgical wound for R#1; and the Medical Director's refusal to send R#1 to the emergency room (ER) for seven days until the resident became septic from his wound. An interview with the Administrator on [DATE] at 3:51 p.m. revealed that the previous Director of Nursing (DON) had been terminated and that the Assistant Director of Nursing (ADON) and Wound Care Nurse had resigned shortly thereafter. The DON was responsible for training facility nursing staff and the agency was responsible for training agency nursing staff on nursing procedures such as wound vac dressing changes. Continued interview revealed that he was not aware that nursing staff had failed to perform weekly skin checks, weekly pressure ulcer assessments or wound treatments as ordered by the Physician. He was not aware that a significant weight loss for R#1 had not been identified. He further stated that this was a nursing issue and would ensure that the current DON addressed those issues. The facility failed to ensure that there was an effective QAPI program that identified quality deficiencies timely, developed and implemented appropriate corrective actions to address those deficiencies and evaluated the effectiveness of the corrective actions to realize and sustain improvements.

Based on record review, review of the Medical Director Agreement (dated [DATE]) and interviews with the Medical Director (Physician CC), Vascular Surgeon (Physician EE) and Social Services Director (SW), the Medical Director failed to refer one resident (R#1) for emergency services for seven (7) days which resulted in the resident becoming septic from his infected surgical wound. In addition, there was no indication that the Medical Director had renewed his annual Medical Director Agreement with the facility on (MONTH) 8, (YEAR) when his previous agreement expired, until (MONTH) 22, 2019. The census was 76 residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director (SW) was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director (SW) as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the Medical Director Agreement (effective [DATE]) revealed that as Medical Director, the Physician CC, would be responsible for the overall coordination of the medical care delivered to the residents of the facility. Responsibilities of the Medical Director included, but not limited, to assist in the development of policies and procedures to govern nursing, medical and other health related services provided; discuss physician practice patterns with attending physicians in incidences of significant variations from the norm; monitor and review attending physicians practice patterns to ensure the effective delivery of medical care and reports to Administration significant variations from the norm; participate in the formulation of written policies for the reporting and controlling of infectious diseases and oversee their implementation; review and take appropriate action on reports from the Director of Nursing regarding significant clinical issues; participate in an effective program of long term care review; and consult with the Administrator on the advisability of creating in-service training programs, particularly in the use of specialized or new equipment and cooperate in developing such programs. 1. An interview with the Medical Director (Physician CC) on [DATE] at 4:10 p.m. revealed that R#1 was readmitted to the facility (on [DATE]) with a wound vac after revision to his left AKA. He gave an order to stop the wound vac and perform wet to dry dressings because none of the nursing staff knew how to work the wound vac. However, he could not remember when he gave the order to stop the wound vac. Continued interview revealed that the surgical wound never healed and that the resident missed several appointments with his Vascular Surgeon (Physician EE). The Medical Director stated at that time that he called the transportation company and complained, although he could not provide any evidence of this phone call. During a clarification interview with the Medical Director on [DATE] at 2:58 p.m., he stated that he saw R#1 on [DATE] and ordered an antibiotic until the resident could be seen by the Vascular Surgeon on [DATE]. He stated that he could not remember if the wound had an odor that day which is the same day that the resident was transferred to another room due to complaints from his roommates of a foul odor from the resident's surgical site. Continued interview revealed that R#1 missed his appointment with the Vascular Surgeon on [DATE] because of transportation problems. A telephone interview with Vascular Surgeon (Physician) EE on [DATE] at 4:47 p.m. revealed that the wound vac was placed on the resident's left AKA after his revision on [DATE] to promote healing of the wound site. He stated that the wound vac was supposed to be changed every Monday, Wednesday and Friday and that staff failure to change the wound vac dressing prevented the removal of any debris absorbed in the sponge. Staff failure to change the dressing every third day prevented them from identifying the deterioration of the wound and any signs of infection early. Continued interview revealed that it was critical that R#1 appear at his [DATE] appointment in order to assess the status of the wound since R#1 had poor circulation. Futher interview with Vascular Surgeon EE revealed that the facility staff had not notified him about the deterioration of the wound or that they did not know how to use the wound vac. He stated that he would have educated facility staff on the use of the wound vac if he had been notified. He stated that on [DATE] the facility Social Services Director notified him that R#1 had fever and a foul odor to his wound and that his attending Physician CC (who was also the Medical Director) would not give an order to send the resident to the hospital. A post survey telephone interview on [DATE] at 3:35 p.m. with Physician EE and his Nurse Practitioner (NP) DD revealed that it was NP DD that had spoken to Physician CC regarding sending R#1 to the emergency room (ER) on [DATE]. NP DD revealed that once she explained to Physician CC that their only office day, was Monday, and that the resident had missed his appointment on [DATE] and on [DATE], he agreed to send the resident to the ER. Continued interview revealed that NP DD stated that Physician CC was not aware of R#1's missed appointments or the Vascular Surgeon availability in the office and as a result agreed to send R#1 to the hospital. Physician EE and NP DD revealed that the facility had not communicated to either of them of the foul odor of the wound, that staff had no idea how to manage the resident's wound vac; that R#1 had stopped eating had developed a Stage IV pressure ulcer and that his health was declining. An interview with the Social Services Director (SW) on [DATE] at 10:06 a.m. revealed that the surgical wound on R#1's left AKA deteriorated. She stated that the nurses were concerned and notified the Medical Director (Physician CC) who ordered an antibiotic. The wound continued to deteriorate but, the Medical Director refused to send the resident to the emergency room (ER) for at least one week. Continued interview revealed that she finally called the Vascular Surgeon on [DATE] to request he intervene on behalf of R#1. There was no indication that the Medical Director coordinated the overall medical care for R#1 to include necessary care and services from his Vascular Surgeon. Although the Medical Director ordered an antibiotic for the resident on [DATE], he failed to send the resident to the emergency room (ER) until [DATE] after intervention by the Vascular Surgeon. There was no indication that the Medical Director consulted with the Administrator about providing training to nursing staff on the use of the wound vac. 2. Review of the Medical Director Agreement with a commencement date of (MONTH) 8, (YEAR) revealed that the agreement ended on the first anniversary of the commencement date. However, there was no indication that the Medical Director Agreement was renewed on (MONTH) 8, (YEAR). The Social Services Director provided a current Medical Director Agreement with a commencement date of (MONTH) 22, 2019. An telephone interview with the Director of Clinical Operations, and a member of the Governing Body, post survey on [DATE] at 2:00 p.m. revealed that neither he or the owner were aware that the facility Business License had expired or that the Medical Director's contract had expired on [DATE], which is the responsibility of the Administrator.

Based on review of the Quality Assurance and Performance Improvement (QAPI) policy dated [DATE], review of the Governing Body Committee Meeting Minutesdated [DATE], review of the Performance Improvement Committee Meeting Minutes dated [DATE] and staff interview, the facility's Governing Body failed to ensure that the Quality Assurance (QA) program was effective in identifying, developing and implementing corrective actions to address concerns with pressure sore and surgical wound treatments for four residents (R#1, 2, 3, 4); significant weight loss for one resident (R#1); notification of the Vascular Surgeon (Physician EE) about the deterioration of the surgical wound for one resident (R#1); and the Medical Director's (Physician CC) refusal to send one resident (R#1) to the emergency room (ER) until he became septic from his infected wound, failed to ensure that the Medical Director contract was current and failed to ensure that a Governing Body Policy and Procedure were in place. The census was 76 residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending Physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the Quality Assurance and Performance Improvement (QAPI) policy dated [DATE] revealed that the Governing Body (GB) consisted of the owner of the facility, Administrator, Director of Nursing (DON) and Director of Clinical Operations. Continued review revealed that the GB was responsible for the development and implementation of the QAPI program. The GB was responsible for setting clear expectations for safety, quality, resident rights, choice and respect; verifying adequate resources exist to conduct QAPI efforts; identifying and prioritizing problems/concerns based on Performance Improvement (PI) data; creating an atmosphere where staff and residents were comfortable identifying quality problems as well as opportunities for improvement; verifying that corrective actions address gaps in the system and are evaluated for effectiveness; and verifying contingency plans for program sustainability during times of leadership transition. Further review revealed that the QAPI committee reported to the GB. Review of the Performance Improvement Committee Meeting Minutes dated [DATE] revealed that the Medical Director, Director of Nursing (DON) SSD, MDS Coordinator and 7 additional department heads were present; however, the Administrator had not signed the Attendees List. The committee discussed multiple issues including care plans and skin assessments. However, review of the information provided by the Social Services Director (SSD) revealed that the minutes did not include a Performance Improvement Plan (PIP) that addressed specific issues related to skin assessments and care plans, corrective measures/interventions that were developed, expected outcomes, completion date or designation of staff who was responsible for monitoring the effectiveness of the interventions. Furthermore, there was no indication that the QAPI committee identified and developed corrective measures to address staff failure to provide pressure ulcer and wound treatments as ordered by the Physician for four residents (R#1, 2, 3, 4) staff failure to identify and address a significant weight loss for R#1; staff failure to notify the vascular surgeon of the deterioration of the surgical wound for R#1; and the Medical Director's (Physician CC) refusal to send R#1 to the emergency room (ER) for seven days until the resident became septic from his wound. An interview with the Administrator on [DATE] at 3:51 p.m. revealed that the previous Director of Nursing (DON) had been terminated and that the Assistant Director of Nursing (ADON) and Wound Care Nurse had resigned shortly thereafter. The DON was responsible for training facility nursing staff and the agency was responsible for training agency nursing staff on nursing procedures such as wound vac dressing changes. Continued interview revealed that he was not aware that nursing staff had failed to perform weekly skin checks, weekly pressure ulcer assessments or wound treatments as ordered by the physician. He was not aware that a significant weight loss for R#1 had not been identified. He stated at that time that this was a nursing issue and would ensure that the current DON addressed those issues. The facility could not provide a Governing Body Policy and Procedure. Review of the Governing Body Committee Meeting Minutes dated [DATE] and emailed to the owner of the facility revealed that the Director of Clinical Operations met with the administrative team that included the Administrator, DON, Social Services Director and other department heads to discuss deficiencies cited during the Standard Survey conducted [DATE]-[DATE]. There was no indication that the GB met again after [DATE]. The Governing Body failed to ensure that the Medical Director's annual contract was renewed as scheduled on (MONTH) 8, (YEAR). His contract was not renewed until (MONTH) 22, 2019. An post survey telephone interview with the Director of Clinical Operations, and a member of the Governing Body, on [DATE] at 2:00 p.m. revealed that neither he or the owner were aware that the facility Business License had expired or that the Medical Director's contract had expired on [DATE], which is the responsibility of the Administrator.

Based on record review, review of the Administrator Job Description and interviews, the facility failed to ensure that the Administrator provided oversight and monitoring of care and services to residents with pressure sores, surgical wounds, weight loss. In addition, the Administrator failed to renew the facility's business license until [DATE], thirty-seven (37) days after the renewal deadline of [DATE], failed to ensure the Medical Director's contract was not expired, failed to ensure there was a licensed Administrator to oversee the facility from [DATE] through [DATE] and failed to ensure that the Clinical Laboratory Improvement Amendments (CLIA) waiver was not expired. The census was 76 residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the Administrator Job Description revealed that the Administrator's supervisory responsibilities included the overall direction, coordination and evaluation of Social Services, Dietary Department, Environmental Department, Activity Department and Administration Department. His essential job functions included directing and coordinating medical, nursing and administrative staff and services; conducting regular rounds to monitor delivery of nursing care and ensure that resident needs were addressed; and directing the hiring and training of personnel. An interview with the Administrator on [DATE] at 4:56 p.m. revealed that he terminated the previous Director of Nursing (DON) on [DATE] and that the previous Assistant Director of Nursing (ADON) quit without notice on [DATE] and previous Treatment nurse quit without notice on [DATE]. A new DON was hired [DATE] but, did not actually work on the floor until [DATE]. The new Treatment nurse was hired approximately ,[DATE] weeks ago. A follow-up interview with the Administrator on [DATE] at 3:51 p.m. revealed that the previous DON was responsible for training facility nursing staff on any new equipment/procedures such as using the wound vac. Continued interview revealed that the staffing agency was responsible for training the agency nurses. An interview with the Administrator on [DATE] at 4:21 p.m. revealed that he attended daily morning meetings with Department Heads to discuss non-nursing issues pertaining to the facility. Continued interview revealed that daily clinical meetings were held by the DON but, he did not attend the clinical meetings. He stated at that time that he received a clinical report of the meetings but, the report did not include specific information about any of the residents discussed. The Administrator failed to ensure that the Medical Director's annual contract was renewed as scheduled on (MONTH) 8, (YEAR). His contract was not renewed until (MONTH) 22, 2019. Review of the current Business License displayed on a wall in the facility revealed an expiration date of [DATE]. Continued review of the license revealed that the renewal deadline was (MONTH) 1, 2019. There was no indication that the license was renewed until [DATE] when a check for $3,873.73 was written to the County Business License Division. Record review of the CLIA waiver revealed that it expired on [DATE] and that there was no evidence that the renewal process had begun. The Administrator was out of the country beginning [DATE] and the facility was without Administrator coverage until [DATE]. The new Director of Nursing and the Social Worker, who is a former Adminstrator, were present during this time. An post survey telephone interview with the Director of Clinical Operations, and a member of the Governing Body, on [DATE] at 2:00 p.m. revealed that neither he or the owner were aware that the facility Business License had expired or that the Medical Director's contract had expired on [DATE], which is the responsibility of the Administrator. He also explained that they were attempting to locate an temporary Administrator for coverage during the Administrator's absence but were not able to secure anyone on a temporary basis. The Administrator failed to monitor, direct and coordinate medical, nursing and administrative staff to ensure that resident needs were addressed and appropriate nursing care was delivered for residents with surgical wounds, pressure sores and weight loss. The Administrator also failed to ensure that nursing staff were trained on the use of vital equipment, i.e., wound vac, necessary for the healing of R#1's surgical wound. The Administrator failed to ensure that the facility's business license and that Medical Director Contract was renewed timely.

Based on record review, staff interviews and Weight Policy and Procedure policy, the facility failed to identify poor intake and to report to the Registered Dietitian (RD) and the facility Physician CC, who is also the Medical Director, R#1's poor oral intake and weight loss and to have timely interventions for an overall 20% actual weight loss and to prevent calories malnutrition and dehydration for one Resident (R) #1 of nine (9) sampled residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the Weight Policy & Procedure Policy: Residents are weighed a minimum of two times each month. Procedure: 6. The Food and Hydration Aide notifies the Registered Dietitian/Diet Technician of residents with a significant with change via WEIGHT, FOOD AND HYDRATION NOTIFICATION form. A significant weight change is indicated by any of the following: - 3 lb weight gain or weight loss/ 7 days. For BMI (Basil Metabolism Rate) that was greater than (>) 19, weight loss of: 3% /14 days, 5% /30 days. 7.5% /90 days, 10% /180 days. For BMI less than (<) 19, weight loss of: 2% /7days. 2% /14 days, 3% /30 day, 7.5% /90 days, 10% /180 days 7. The Registered Dietitian/Diet Technician asses each resident with a significant weight change, makes appropriate recommendations to Physicians and updates the resident's plan of care. Review of the Admission Record, dated [DATE], and the [DIAGNOSES REDACTED].#1 had the following [DIAGNOSES REDACTED]. Review of the Weight and Vitals Summary revealed that R#1 weight on [DATE] was 160 and weight on [DATE] was 118 pounds. Review of the facility Weekly Weights form dated [DATE] through [DATE] revealed R#1 on [DATE] had a re-admission weight of 133 pounds (lbs) which was posted under [DATE]. He continued to be on weekly weeks until [DATE]. Those weekly weights were [DATE] 133 pounds, [DATE] 138 pounds, [DATE] 125 pounds, and [DATE] 122 pounds. R#1 weekly weight was discontinued on [DATE], even though the resident had a 11 pound (8%) weight loss within the four (4) weeks. There was no other documentation to determine why R#1 had been discontinued from weekly weights after an 8% weight loss within one (1) month. Review of the facility Monthly Weight Record revealed R#1 weights were: [DATE] - 133 pounds [DATE] - 118 pounds an 11% weight loss in one month [DATE] - 106 pounds an 20% weight loss in two months Review of the Progress Notes Nutrition/Dietary Note dated [DATE] was the only entry for the current year. The Registered Dietitian (RD) noted that R#1 had a wound on his left stump and a stage 1 on his sacrum. It is also, noted that resident was receiving Health Shakes, multivitamins (MVI) and Pro-stat to promote healing of wounds. He does have bilateral AKA. No new weight on chart at this date. Could not finish nutritional assessment. There is no other documentation as to the reason, R#1 was receiving health shakes, multivitamins and the Pro-stat other than the physician's orders [REDACTED]. Review of the Nutrition - Amount Eaten dated [DATE] through [DATE] revealed that the documentation reflected R#1 consumption for 1 - 3 meals per day. In February, on [DATE], there are no meals documented before and after R#1 return from his appointment. On [DATE] indicated R#1 missed lunch. In (MONTH) 2019, there is no documented meal consumption for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Beginning on [DATE], R#1 constantly consumed ,[DATE] % meals with two (2) days refusing the breakfast meals ([DATE], [DATE]). Review of the Order Recap Report dated [DATE] through [DATE] revealed that R#1 had orders for No Added Salt (NAS) diet, regular texture and Health Shakes one time daily with a start date of [DATE]. A Physician order [REDACTED]. Record review of the Medication Administration Record [REDACTED]. Review of the hospital History and Physical dated [DATE] revealed R#1 had an admitting [DIAGNOSES REDACTED]. The resident is assessed in the Emergency Center (EC) with acute or chronic [MEDICAL CONDITION] with a hemoglobin of 6.0 (13XXX,[DATE].5), electrolyte derangement with [DIAGNOSES REDACTED], [MEDICAL CONDITION], [DIAGNOSES REDACTED] and elevated Blood, Urea, Nitrogen (BUN). Laboratory results in the Emergency Center were documented as: Sodium (NA) was 153 (,[DATE]), Potassium (K+) was 3 (3XXX,[DATE].1), BUN was 27 (6XXX,[DATE]), Calcium was 7.3 (8XXX,[DATE].20), serum [MEDICATION NAME] was 1.4 (3XXX,[DATE].8). An interview on [DATE] at 10:46 a.m. with Certified Nurse Aide (CNA) II revealed that she will chart her activity of daily living (ADL) in the computer. She would report to the charge nurse when a resident is not eating. She would then go to the Dietary Manager (DM) to get and offer the resident a substitute. If need be, will try to assist with feeding. An interview on [DATE] at 10:49 a.m. with Restorative CNA JJ revealed that she had obtained the (MONTH) 2019 weights. She further revealed that the DM normally put the weights in the electronic record. An interview on [DATE] at 10:51 a.m. with Restorative CNA KK revealed that if any discrepancy in a residents' weight is noted then she will re-weigh the resident and will talk to the nurse, responsible for Restorative aides and the DM. She revealed that R#1 was never placed on restorative dining. She further revealed that when the resident had stop eating that she told the DM, the previous Director of Nursing (DON) and the previous treatment nurse. She explains that the previous treatment nurse was over the restorative, and no one got back with them to give them any additional instructions if the resident was to continue on weekly weights. An interview on [DATE] at 10:57 a.m. with the DM revealed that the weight data was to be entered into the electronic record by the Director of Nursing (DON), but she would put the weights in when she had time. For (MONTH) 2019 weights that were not in the electronic record, she used the restorative weight sheets to calculate residents' weights. She further revealed that weights were not being discussed in the morning meetings. She was not aware or had been informed that R#1 was not eating although he was already on Health Shakes prior to her be hired in ,[DATE]. An interview on [DATE] at 11:04 a.m. with the Registered Dietitian (RD) revealed that she was not aware that R#1 was not eating. She stated that she received her wound stage from the previous treatment nurse. She visits the facility once per month and physically sees each resident. When she came in (MONTH) 2019, R#1 was still able to feed himself. Her only concern was that the resident had bilateral AKA and his left AKA was not healing. An interview on [DATE] at 4:40 p.m. with Physician CC, who is also the Medical Director, revealed that he could not recall ordering Pro-stat for R#1 and could not recall if had been notified of the weight loss. But did give an order on [DATE] for [MEDICATION NAME] and [MEDICATION NAME] when he was notified of the resident's Stage IV pressure ulcer and that he was not eating much. An interview with CNA RR on [DATE] at 10:14 a.m. revealed that she had cared for R#1 in (MONTH) 2019. She revealed that once the resident was moved from the ward to another room (on [DATE]) the resident quit eating. She had reported this to the LPN AA who instructed her to give him the Health Shakes. She further reported at that time, the resident had very little intake, only sips were taken. She reports the resident had a sunken look and his lips were dry, and he had stopped eating and drinking during the last week in the facility which was reported to the agency nurses. Cross refer F580, F600

Based on record review and staff interview, the facility failed to ensure that licensed/registered nursing staff monitored the status of a surgical wound, provided treatments as ordered by Physician CC (Medical Director) and notified the Vascular Surgeon (Physician EE) of the deterioration of the surgical wound timely for one resident (R#1); failed to remove embedded sutures in the left below knee amputation (BKA) site timely and provide treatments as ordered for one resident (R#2) of nine sampled residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: 1. Review of the Admission Record and the [DIAGNOSES REDACTED].#1 (R#1) had the following [DIAGNOSES REDACTED]. Review of a local hospital Discharge Summary dated [DATE] revealed R#1 was readmitted to the facility with status [REDACTED]. R#1 was to follow-up with Vascular as outlined by them. R#1 was scheduled on [DATE] with the Vascular Surgeon for an incision check. The facility failed to make transportation arrangement for this appointment. Review of the R#1 care plan, not dated, revealed that he was at risk for alteration in skin integrity related to [DIAGNOSES REDACTED]. The interventions were treatments as ordered; encourage and assist with adequate nutrition intake and notify the physician as needed. There was no care plan developed or an update after the resident's readmission for the left above the knee (AKA) amputation Review of the physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed that there was no evidence that the treatment had been completed on [DATE], [DATE], [DATE], [DATE], or [DATE]. Review of the Progress Note dated [DATE], signed by Licensed Practical Nurse (LPN) VV revealed writer observed stump to have seven staples still intact, wound dehiscencing (splitting open), small amount of drainage, a foul odor, and hardened darkened black areas to stump surgical site. Resident verbalizes that the smell coming from his stump makes him sick on his stomach. No vomiting noted. Resident's temperature is remaining a low grade one, since the removal of resident's left leg. Treatment to left stump ongoing. There was not evidence that the surgeon or facility Physician were notified. Although the resident was started on [MEDICATION NAME] 750 milligrams (mg) on [DATE]. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the facility treatment nurse had contacted the office reporting that the resident has a scheduled visit on [DATE] and the left AKA looks a little worse. She reports no redness or inflammation to the site today. She states the area was drying out, but yesterday the resident had yellow/white drainage present with a mild odor. It looks like the area is opening up all across the surgical incision except at the eschar, no chills, cleaning area with normal saline daily, no increased pain reported by patient to stump. No fever today but had a low-grade temp on [DATE]. Wound treatment changed to Santly around left AKA edges and wet/dry dressing to middle of wound daily and keep follow up appointment this Monday. Let the treatment nurse know that we will be referring the patient to the Wound Clinic for wound treatment. A follow up note dated [DATE] to the Surgeon's office from the treatment nurse: The treatment nurse commented that the resident might be soiling his surgical dressing when urinating and that the rehab Physician CC might be starting the patient on [MEDICATION NAME] today. Review of Progress Notes dated [DATE] revealed that the resident's left stump continues to be draining yellowish white fluid, area to middle of wound has dehisced held together by steri-strips at the present. Eschar noted to right edge of wound with foul odor. Continue on antibiotics until postop appointment on [DATE]. Will continue to monitor for any changes. Attempted to contact family. Review of the Vascular Surgeon's (Physician EE) office Progress Notes, dated [DATE], revealed the resident left AKA nonhealing with wound disruption, non-infected. Plan surgical debridement and wound vac placement on Thursday. Review of the Operative Report, dated [DATE], revealed the resident underwent [REDACTED]. Wound vac to be changed every third day. Review of the hospital Discharge Orders dated [DATE] (Saturday) revealed the resident was discharged on multiple medications, including [MEDICATION NAME] 750 mg one daily. Additionally, the resident had orders to change the Wound vac every three days on Monday, Wednesday and Friday (M, W, F) with continuous suction at 75 centimeters (cm) of negative pressure. Please send dressing change supplies to the office on (MONTH) 25 the for wound vac changes. Review of the Treatment Administration Record (TAR) revealed that the wound vac was not changed until Wednesday, [DATE], rather than on [DATE]. Further review revealed a new order was noted to decrease the pressure to 70 and continue changes on M, W, F. The wound vac was documented as changed on [DATE], [DATE] and [DATE]. There is no evidence the wound vac was changed thereafter. Record review of a Progress Note, dated [DATE] at 3:05 a.m., revealed that the resident arrived at the facility on [DATE] at 7:00 p.m., in a wheelchair, via transportation. Resident complains of pain to the left stump and pain medication was given. Record review of a Progress Note, dated [DATE] and signed by the Wound Nurse, revealed that during dressing change wound bed is approximately 2.5 cm deep with yellow slough, small amount of serous drainage with a foul odor noted. Wound has A cell wound matrix layer matrix and xeroform gauze stapled to skin edges. Record review of a Progress Note dated [DATE] signed by Physician CC (also the Medical Director) revealed resident has bilateral AKA that had to be revised due to infection and poor healing. He now has a wound vac, on [MEDICATION NAME] 750 mg daily. He is declining rapidly despite everything we are doing. His blood sugar is 177, weight down to 118 pounds, vital signs stable. His revision looking better. I'll see him in two weeks. Record review of Progress Notes dated [DATE] at 15:06 (3:06 p.m.) revealed the resident noted to be very confused and disoriented. During wound care writer noted increased foul odor to the left stump. Temperature is 100.4 resident's body warm to touch. MD notified with orders to send to emergency room (ER) for evaluation. RP notified. Wound vac disconnected, cleaned with normal saline gauze and dry dressing applied. Resident transported to ER at 2:00 p.m. via stretcher. Record review of the hospital History and Physical dated [DATE] revealed had a left AKA on [DATE] and a revision on [DATE]. The resident has altered mental status. The resident reportedly missed several follow up appointment with vascular to the AKA surgey in January. He required a revision to the surgical wound with a wound vac placed with instructions to be changed three times per week. The SNF (facility) SW called the patient's PCP, who upon assessment feared the patient has become septic so the patient was sent to the Emergency Center (EC). The patient's left AKA site appears to be infected, likely gangrenous, bone is visible, eschar and malodorous. The resident temperature is 100.4 degrees. The resident's weight was 52 kilograms (114.4 pounds). Assessment:[MEDICAL CONDITION] due to wound infection, left AKA site infection-likely wet gangrene, acute or chronic [MEDICAL CONDITION]-Hgb 6.0, dehydration with electrolyte derangement-[DIAGNOSES REDACTED], [MEDICAL CONDITION], [DIAGNOSES REDACTED], elevated BUN, severe protein calorie malnutrition. Record review of Consultation report by Physician EE (Vascular Surgeon) dated [DATE] revealed that the resident was not transported for follow up care on [DATE] and that the facility declined offer for appointment on [DATE] secondary to transportation. Today the SNF SW called to ask for resident to be seen, at the instructions of Physician CC for fear the resident was becoming septic. Nurse Practitioner (NP) DD called Physician CC to ask for the patient to be sent to the EC for evaluation. Plan for Operation tomorrow for left AKA revision. Record review of the Physician EE's office notes dated [DATE] at 12:33 p.m. revealed that the facility SW called the office requesting an appointment for R#1 today. She states that something is going on in the resident groin that has the wound vac and the patient needs to see the doctor ASAP (as soon as possible). She states they are concerned he may be septic, states he has fever and chills for ,[DATE] days, wound smells awful and he has been talking out of his head the past few days. She states the attending Physician at the facility (Physician CC) will not write orders to have the patient sent to the EC for evaluation, but states the patient needs to go to Physician EE's office for evaluation. She states the wound care nurse walked out of the facility last week and the nurses on the floor have been treating this patient's wound the best they know how. Action Taken: SW was informed that Physician EE is not n the office today, that his office day is on Monday's. Told her the patient had an appointment on [DATE] that the patient was a no show and last Friday when they were rescheduling the resident's appointment to [DATE], the facility refused due to needing three days for transport. States that she made arrangements with transport company for [DATE] but they never showed up and this happens frequently with the transportation company. Made her aware patient needs to go to the EC for evaluation and that Physician EE can see the resident in the EC. She states that Physician CC refuses to write the order and states that Physician EE needs to write the order. The NP DD made contact with Physician CC and the resident is coming to the EC. Review of the Operative Report dated [DATE] revealed that four additional inches were removed from the resident left stump in order to reach viable tissue. Plan: Wound check in ,[DATE] weeks Review of the hospital Discharge Summary dated [DATE], revealed the resident developed a code blue (arrest) at 7:00 a.m. He received Advanced Cardiac Life Support (ACLS) for 20 minutes plus and reportedly lost pulse twice in the interim. Due to poor prognosis and prolonged attempt to resuscitate, ACLS efforts were called at 7:31 a.m. Assessment:[MEDICAL CONDITION] due to left AKA stump wound infection, wet gangrene, severe protein calorie malnutrition, low [MEDICATION NAME] and pre-[MEDICATION NAME]. An interview on [DATE] at 9:46 a.m. with Licensed Practical Nurse (LPN) AA revealed that she received an order on [DATE] to send R#1 to the hospital. The new Director of Nursing (DON) was the person who removed the [DEVICE] on [DATE]. The DON removed the wound vac but was unable to reconnect the [DEVICE] to R#1 stump. The treatment nurse had already quit and there was no other nurse in the building who had been trained on the wound vac or were familiar with the wound vac. After the treatment nurse quit, the wound vac dressings were not change. She was not aware if the Physician was aware or knew no one was doing the [DEVICE] dressings changes. She further revealed that the nurses did not receive training for the wound vac. She further revealed that R#1 had missed at least four of his appointments with the surgeon. An interview on [DATE] at 4:10 p.m. Physician CC revealed that the R#1 had developed a wound on his foot (left). He referred the resident to the vascular clinic. Resident had severe [MEDICAL CONDITIONS] and in (MONTH) the resident had an above the knee amputation (AKA). The amputation deteriorated and resident had a [DEVICE] place. He stated that the facility has had a lot of turn over. He further revealed that he could not remember when he gave the order to stop the [DEVICE], but he gave an order for [REDACTED]. He was aware that the resident had missed several appointments and that he called transportation services, himself, to complain although he could provide no documentation as to who he called or when he called the transportation company. Physician CC revealed that R#1 died in the hospital and he did not know the cause of death. An interview with the Administrator on [DATE] at 4:56 p.m. revealed that the DON was terminated on [DATE]. The Assistant DON (ADON) and the Treatment Nurse left without notice. The ADON resigned without notice on [DATE] and the Treatment Nurse resigned without notice on [DATE] although her last day working at the facility was [DATE]. The Administrator further revealed that they utilized agency nurses thereafter. An interview on [DATE] at 7:55 a.m. with Nurse Practitioner (NP) DD, who is employed by the Vascular Surgeon, revealed that an amputation normally heals without having to do a [DEVICE]. When an amputation is not healing, then the [DEVICE] is placed to promote healing which needs to be changed every third day. She revealed that the resident has had missed appointments for follow up visits. She was aware that Physician CC went to see the resident at the facility on [DATE] and did not send him to the hospital. On [DATE], Physician CC had to be asked to send resident to the Emergency Center (EC). The resident's stump was terrible, odorous and could smell the odor from the ER room. R#1 presented to the ER with bone exposed, deteriorated at the suture line and up to the inner leg. The resident had to be taken to surgery to removed four (4) inches from the remaining stump to reach viable tissue. The bottom line the resident had develop an anal fistula, at the Stage IV pressure ulcer area, that was constantly leaking and was contaminating the left stump wound. The stump had significantly deteriorated from the last time it was seen by Physician EE. A subsequent interview on [DATE] at 2:58 p.m. Physician CC revealed that on [DATE] he saw the resident and started the resident on oral [MEDICATION NAME] until the resident could be seen by the surgeon on [DATE]. He could not recall if there was a strong odor when seeing the resident on this visit. The resident missed that appointment due to transportation. On [DATE], he gave the order to send the resident to emergency room (ER) for evaluation. Physician EE, the Surgeon, was on call that evening. An interview on [DATE] at 4:47 p.m. with R#2, who was R#1's roommate, revealed that the R#1's stump became infected and the odor was bad. He had complained to staff and the resident was moved to another room. An interview with R#8 on [DATE] at 11:58 a.m., a former roommate of R#1 (who was in a multiple bed ward at that time), revealed that the R#1 had a smell and some sort of machine to this leg. The smell was weird and strong. He had reported it to one of the nurses and then R#1 was moved to another room. An interview on [DATE] at 10:14 a.m. with CNA RR who revealed that about one to two weeks after R#1 returned from the revision, he became delusional. He was constantly turning on his call light then saying outlandish things such as he needed to get up and walk. The smell from him was like something rotten, decaying. The smell was so bad that you needed to open the windows. The treatment nurse would spray disinfecting spray. The wound started smelling after the wound vac was placed and the contents in the vacuum container looked like pus. He was moved out of the ward to another room due to smell and then he stopped eating. She had reported it to LPN AA who told them just to give him health shakes but even with assistance he wouldn't eat much. She revealed that on [DATE] that LPN AA and the agency nurse were working with his wound vac, attempting to figure out what to do and it wasn't working. She further revealed that the resident had a sunken look, his lips were dry and cracked. During an interview on [DATE] at 12:04 p.m. the current DON revealed that the wound suction canister was ¾ full. This was the first time he actually seen the wound, which was on [DATE]. He further stated that Physician CC was dragging his feet about sending the R#1 to the hospital. We (SW) called the vascular clinic to get assist with sending the resident out. An interview on [DATE] at 4:47 p.m. with Physician EE revealed that when R#1 was seen for the [DATE] appointment, there was no need for a culture, the wound was not infected. On [DATE] the wound was debrided of necrotic tissues and a wound vac was placed to promote the healing of the surgical site. Physician EE further revealed that the [DEVICE] dressing changes were ordered to be changed Monday, Wednesday and Fridays and not changing the dressing would have a detrimental impact on the wound. The scheduled changes would ensure the tissue in the wound is healthy and remove the debris absorbed in the sponge. By not changing the sponge every third day would prevent staff from seeing signs of infection and wound deteriorating. Physician EE further revealed that the [DATE] was a critical appointment to access the progress of healing. The resident had poor blood supply to his stump, and this was the reason his stump was slow healing. The resident was seen by the EC Physician once he arrived on [DATE] at 4:15 p.m. The stump was described as having the bone exposed, bad odor, wet gangrene and dead tissue. The facility had not communicated with him on the condition of the wound. He further revealed that that had the facility communicated with him the lack of nurses who could change the wound vac then he would have helped the facility to facilitate the use of the [DEVICE]. Physician EE confirmed that the resident expired on [DATE] at 10:00 a.m. with a cause of death due [MEDICAL CONDITION] secondary to AKA infection An interview with the SW on [DATE] at 2:00 p.m. revealed that she had contacted Physician EE's office seeking help for R#1. She stated that Physician CC would not give an order to send the resident to the hospital and she was very concerned about the resident. She further stated that staff had been trying, for about a week, to get Physician CC to send the resident to the ER because he was getting worse, his wound smelled so badly, and the resident was becoming more confused. She confirmed that the resident was transferred to a semi-private room, without a roommate, on [DATE] due to complaints of the odor by the resident's roommates. The SW stated she may have mentioned to the Administrator regarding Physician CC refusing to send the resident to the ER but since he was not clinical, she may not have gotten into the details about the situation. Cross refer F580, F600, F656, F835, F837, F841, F867 2. Review of the medical record for R#2 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Notes, dated [DATE] at 7:40 p.m., revealed that R#2 was admitted to the facility on [DATE] with sutures noted on his left BKA site. Physician CC, who was also the Medical Director, was notified and ordered licensed/registered nursing staff to apply triple antibiotic ointment (TAO) to the resident's left stump every day shift and leave open to air. Review of the Treatment Administration Records (TARS) for ,[DATE] and ,[DATE] revealed that licensed/registered nursing staff failed to provide treatment as ordered on Saturday [DATE] and Tuesday [DATE]. Review of the TAR for ,[DATE] revealed that treatments were done as ordered except on [DATE] and [DATE] due to the resident's refusal. Review of the TAR for ,[DATE] revealed that licensed/registered nursing staff failed to provide treatment as ordered on Saturday [DATE]. Review of the Late Entry Skin/Wound Note dated [DATE] at 11:10 a.m. revealed that Registered Nursing staff attempted to make a follow-up appointment with the surgeon who performed the amputation to the resident's left leg. However, R#2 did not remember the name of the surgeon who performed his left BKA or the hospital where the procedure was done. Continued review of the Progress Note revealed that several attempts to contact his surgeon at nearby orthopedic clinics were unsuccessful. The Admissions Coordinator was instructed to request additional hospital records from the hospital the resident was discharged from prior to his admission to the facility. Further review revealed that Physician CC was notified and ordered staff to refer the resident to the surgeon who performed his amputation. Review of the Skin/Wound Note dated [DATE] at 1:04 p.m. revealed that the resident's left BKA was partially healed with sutures embedded into the skin. The left outer corner of the stump had a small opening with yellow drainage noted. Physician CC was notified and ordered licensed nursing staff to apply Mupirocin ointment (an antibiotic ointment) to the left stump every day. Review of the Progress Note dated [DATE] at 10:33 a.m., which were documented by the previous Director of Nursing (DON), revealed that Physician CC was notified about the sutures in R#2's left stump and that staff were unable to identify which surgeon had performed his left BKA. Physician CC ordered licensed nursing staff to remove the sutures, clean the left stump with normal saline or wound cleanser and apply [MEDICATION NAME] ointment (an antibiotic ointment) and cover with a dry dressing daily for five (5) days. Review of the Skin/Wound Note dated [DATE] at 11:36 a.m. revealed that the Registered Nurse and DON removed the resident's sutures with a scant amount of blood noted. The resident tolerated the procedure well. The facility failed to ensure that embedded sutures in the left BKA site for R#2, which were identified on his admission on [DATE], were removed until [DATE]. Furthermore, there was no indication that licensed/registered nursing staff provided treatments as ordered by the Physician on [DATE], [DATE] and [DATE].

Based on record review, review of the facility policy and procedure titled Care Plan Protocol (revised [DATE]) and staff interview, the facility failed to develop care plans with appropriate interventions to address the assessment, monitoring and treatment of [REDACTED].#1); failed to follow the care plan to consult the Registered Dietician (RD) and physician about a significant weight loss for one resident (R#1); failed to develop a care plan to address the imbedded sutures in the left below knee amputation (BKA) site for one resident (R#2); and failed to develop care plans with appropriate interventions for staff to perform weekly skin checks to identify breakdown timely and weekly pressure ulcer assessments to monitor the status of the sacral pressure ulcers for two residents (R#3, R#4) of nine sampled residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order for [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the Care Plan Protocol Purpose: To ensure care plans are developed, initiated and meet Nursing Standards and Regulations. Protocol: 1. Upon Admission (unless a Comprehensive Plan of Care (P[NAME]) is already in place) a Base Line of Plan of Care will be developed. The BP[NAME] (Baseline Plan of Care) will be reviewed with the Resident and/or RP within 72 hours. 2. The BP[NAME] will remain in place until the Comprehensive Assessment is completed and the Comprehensive P[NAME] is developed within 21 days by the IDT. 3. Additions to a current care plan will dated to indicate the implementation date of the problem/intervention. Revised [DATE] 1. Review of the R#1 care plan, not dated, revealed that he was at risk for alteration in skin integrity related to [DIAGNOSES REDACTED]. The interventions were treatments as ordered; encourage and assist with adequate nutrition intake and notify the Physician as needed. However, the facility failed to develop and implement a care plan for R#1 sacral wound and his surgical wound to his left stump. The sacral wound was identified on [DATE] as a stage 1 and by [DATE] had deteriorated to a stage IV. There were no interventions identified to prevent further breakdown or to promote the healing of the sacral wound. The surgical wound site had not been addressed from the initial date of [DATE] nor prior to the resident being readmitted to the hospital on [DATE] Review of the nutritional care plan, not dated, revealed that R#1 was at risk for alteration in nutrition related to the need for a therapeutic diet and poor dental status; resident refuses to be weighed without his prosthesis. The resident goes to the dining room for meals. The interventions noted were Registered Dietitian (RD) consult as needed; serve diet as ordered; honoring preferences and offering substitutes as appropriate; notify the Physician as needed; and offer supplement shake at lunch. The resident had a 11% weight loss between [DATE] and [DATE] and a 10% weight loss between [DATE] and [DATE] for a total of 20% weight loss in 60 days. An interview with License Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator on [DATE] at 12:06 p.m. revealed that she completed an assessment one week prior to R#1 going to the hospital. The assessment found that the resident was still talking and alert, had asked for a coke, and still had the [DEVICE]. The facility did not follow the care plan for notifying the Physician or consulting with the RD as needed. Cross Refer to F684, F686 and F692. 2. Review of the medical record for R#2 revealed that he was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Progress Note dated [DATE] at 7:40 p.m. revealed that R#2 was admitted to the facility on [DATE] with sutures noted in his left BKA site. Physician CC, who was also the Medical Director, was notified and ordered licensed/registered nursing staff to apply triple antibiotic ointment (TAO) to the resident's left stump every day shift and leave open to air. Review of the Skin/Wound Note dated [DATE] at 1:04 p.m. revealed that the resident's left BKA was partially healed with sutures embedded into the skin. The left outer corner of the stump had a small opening with yellow drainage noted. Physician CC was notified and ordered licensed nursing staff to apply Mupirocin ointment (an antibiotic ointment) to the left stump every day. Continued review of the resident's medical record revealed [REDACTED]. Review of the care plan for R#2 (no date) revealed a potential impairment to his skin integrity due to his bilateral BKAs, diabetes and immobility and that his left BKA was being treated and followed by the wound nurse. Interventions for staff included to encourage good nutrition and hydration in order to promote healthier skin; follow facility protocols for treatment of [REDACTED]. However, there were no interventions developed that addressed the removal of the embedded sutures in the resident's left stump. Cross refer to F684. 3. Review of R#3 care plan, not dated, revealed that she had an alteration in skin integrity. Resident has a pressure ulcer to her sacrum. Her interventions were listed as treatments as ordered; observed for/report objective signs of infection and/or worsening status. The facility previous treatment nurse did not have any documentation available that weekly skin checks were performed or that weekly wound measurement for [DATE] through [DATE] were obtained by the treatment nurse. Cross Refer to F686. 4. Review of R#4 care plan, not dated, revealed resident was at risk for altered skin integrity, related to altered elimination, impaired mobility and stage 4 pressure area to sacrum. With an Interventions/Tasks to observed for and report changes in skin color, texture or integrity. There is no documentation that the facility previous treatment nurse was completing weekly skin monitoring of the sacral wound. There were two skin observation tool (dated [DATE], [DATE]) that the previous treatment noted as pressure ulcer to sacrum. There were no measurements for either dates or additional documentation available of on wound care monitoring by staff. Cross Refer to F686. An interview on [DATE] at 12:06 p.m. License Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator, who was hired on [DATE], revealed that she had not had a chance to review all the care plans yet. She confirmed that the care plans for R#1 was not reviewed prior to his discharge to the hospital on [DATE]. She also confirmed that the care plans for R#2, R3# and R#4 had not been reviewed to date. She further stated that the care plan meetings had not been done although they began this month (May) and she had started the 72-hour meetings again.

Based on record review, review of the facility policy and procedure titled Abuse, Neglect, Exploitation, Misappropriation of Resident Property (revised [DATE]) and staff and resident interviews, the facility failed to ensure that licensed/registered nursing staff monitored the status of a surgical wound, provided treatments as ordered by the Physician and notified the surgeon of the deterioration of the surgical wound timely for one resident (R#1); failed to perform weekly skin checks to identify breakdown timely and then failed to consistently assess the status of the developing sacral pressure ulcer until it was a Stage IV and required debridement for one resident (R#1); and failed to identify a significant weight loss and notify the Physician and Registered Dietician (RD) timely so that interventions to prevent further weight loss could be implemented for one resident (R#1) of nine sampled residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order for [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending Physician CC (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the facility policy Abuse, Neglect, Exploitation, Misappropriation of Resident Property (revised [DATE]) revealed that the Administrator was responsible for the facility Abuse/Neglect Prevention Program. Continued review revealed that the facility would follow state and federal guidelines on preventing neglect which was defined as the failure of the facility, its employees or facility service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish or emotional distress. The facility would educate staff upon hire and annually thereafter regarding the facility's policy. All staff were responsible for monitoring the care and treatment of [REDACTED]. needs. Review of the Admission Record, dated [DATE], and the [DIAGNOSES REDACTED].#1 (R#1) had the following [DIAGNOSES REDACTED]. Review of a local hospital History and Physical dated [DATE] revealed R#1 was admitted to the hospital for worsening left lower extremity (LLE) wound. R#1 presented to the hospital with a history of having developed blisters and sores between the toes on the left foot. Upon evaluation of the left foot, it was determined that the foot was cold and pulseless, and the lower extremity was dark. A Vascular Surgeon was consulted with the plan was to perform an amputation. Review of the Discharge Summary dated [DATE] revealed R#1 would follow-up with Vascular as outlined by them. R#1 was scheduled on [DATE] with the Vascular Surgeon for an incision check. There was no evidence that the resident went to this appointment. Review of the Physician's Orders for (MONTH) 2019 re-admission revealed an order to clean left stump with normal saline or wound cleanser, pat dry, apply triple antibiotic ointment, cover with a dry dressing daily, every day shift beginning [DATE]. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed that there was no evidence that the treatment had been completed on [DATE], [DATE], [DATE], [DATE], or [DATE]. Review of the Progress Note dated [DATE], signed by Licensed Practical Nurse (LPN) VV revealed writer observed stump to have seven staples still intact, wound dehiscencing (splitting open), small amount of drainage, a foul odor, and hardened darkened black areas to stump surgical site. Resident verbalizes that the smell coming from his stump makes him sick on his stomach. No vomiting noted. Resident's temperature is remaining a low grade one, since the removal of resident's left leg. Treatment to left stump ongoing. There was no evidence that the surgeon or facility Physician were notified. Although the resident was started on [MEDICATION NAME] 750 milligrams (mg) on [DATE]. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the facility treatment nurse had contacted the office reporting that the resident has a scheduled visit on [DATE] and the left AKA looks a little worse. She reports no redness or inflammation to the site today. She states the area was drying out, but yesterday the resident had yellow/white drainage present with a mild odor. It looks like the area is opening up all across the surgical incision except at the eschar, no chills, cleaning area with normal saline daily, no increased pain reported by patient to stump. No fever today but had a low-grade temp on [DATE]. Wound treatment changed to Santly around left AKA edges and wet/dry dressing to middle of wound daily and keep follow up appointment this Monday. Let the treatment nurse know that we will be referring the patient to the Wound Clinic for wound treatment. A follow up note dated [DATE] to the surgeon's office from the treatment nurse: The treatment nurse commented that the resident might be soling his surgical dressing when urinating and that the rehab Physician might be starting the patient on [MEDICATION NAME] today. Review of Progress Notes dated [DATE] revealed that the resident was noted to have a Stage I pressure ulcer to the sacrum. Left stump continues to be draining yellowish white fluid, area to middle of wound has dehisced held together by steri-strips at the present. Eschar noted to right edge of wound with foul odor. Continue on antibiotics until post-op appointment on [DATE]. Will continue to monitor for any changes. Attempted to contact family. Review of the Vascular Surgeon's office Progress Notes, dated [DATE], revealed the resident Left AKA nonhealing with wound disruption, non-infected. Plan surgical debridement and wound vac placement on Thursday. Review of the Operative Report, dated [DATE], revealed the resident underwent [REDACTED]. Placement of an ACell wound matric layer, Placement of a wound vac dressing. Wound vac to be changed every third day. Review of the hospital Discharge Summary dated [DATE] revealed that discharge was held yesterday due to facility staffing. discharged this morning (am). Discharge patient with wound/dressing care. Review of the hospital Discharge Orders dated [DATE] (Saturday) revealed the resident was discharged on multiple medications, including [MEDICATION NAME] 750 mg one daily. Additionally, the resident had orders to change the Wound vac every three days on Monday, Wednesday and Friday (M, W, F) with continuous suction at 75 centimeters (cm) of negative pressure. Please send dressing change supplies to the office on (MONTH) 25 the for wound vac changes. Review of the Treatment Administration Record (TAR) revealed that the wound vac was not changed until Wednesday, [DATE], rather than on [DATE]. Further review revealed a new order was noted to decrease the pressure to 70 and continue changes on M, W, F. The wound vac was documented as changed on [DATE], [DATE] and [DATE]. There is no evidence the wound vac was changed thereafter. Record review of a Progress Note, dated [DATE] at 3:05 a.m., revealed that the resident arrived at the facility on [DATE] at 7:00 p.m., in a wheelchair, via transportation. Resident complains of pain to the left stump and pain medication was given. The resident had open areas to sacral area which were cleaned with normal saline, applied ointment and covered with a dressing. Resident pulse on admission was 133 beats per minute which was out of range but decreased to 108 bpm at 3:48 a.m. Resident has a follow up appointment for wound check and staple removal. There was no evidence of wound notes to describe the sacral wound or measurements. Record review of a Dietitian Progress Note, dated [DATE], revealed there was no Braden scale on chart. Resident on No Added Salt (NAS) diet regular texture, can feed self and consumes ,[DATE]% of the food. He does have wound on Left stump, Stage I on sacrum. He is on Health shakes, Multi-dose vitamins (MDV) and Pro-stat to promote wound healing. He does have bilateral AKA. No new weight on chart at this date. Could not finish nutritional assessment. Record review of R#1's Nutrition-Amount Eaten for (MONTH) 2019 revealed that from [DATE] until [DATE] the resident's intake was ,[DATE]%. Beginning [DATE] through [DATE] the resident's intake was ,[DATE]% for all meals. The resident intake beginning [DATE] through [DATE] was noted as diminished ranging from ,[DATE]%. Review of the (MONTH) 2019 intake revealed that from [DATE] (resident was in the hospital [DATE]-[DATE]) the resident's intake was ,[DATE]% with frequent refusals. Record review of the (MONTH) 2019 Medication Administration Record [REDACTED]. Record review of a Progress Note, dated [DATE] and signed by the Wound Nurse, revealed that during dressing change wound bed is approximately 2.5 cm deep with yellow slough, small amount of serous drainage with a foul odor noted. Wound has A cell wound matrix layer matrix and xeroform gauze stapled to skin edges. Continues MDV, Pro-stat for wound healing. Resident also has a Stage I to sacrum, no odor or drainage noted to this site. Surgeon's Nurse Practitioner (NP) DD was notified and received new orders to draw CBC (Complete Blood Count) on next lab day. Will continue to monitor. There was no evidence of wound notes to describe the sacral wound or measurements. Record review revealed that a Complete Blood Count (CBC) was drawn on [DATE] which was abnormal with a White Blood Count of 17.5 (3XXX,[DATE].5), Hemoglobin (Hbg) 8.2 (13XXX,[DATE].5) and Hematocrit of 25.2 (38XXX,[DATE].0). Written on the lab report indicated that Nurse Practitioner (NP) DD was notified with no new orders. Record review of a Progress Note dated [DATE] signed by Physician CC (Medical Director) revealed resident has bilateral AKA (left AKA) that had to be revised due to infection and poor healing. He now has a wound vac, and on [MEDICATION NAME] 750 mg daily. He is declining rapidly despite everything we are doing. His blood sugar is 177, weight down to 118 pounds, vital signs stable. His revision looking better. I'll see him in two weeks. Record review of a Progress Note, dated [DATE] signed by LPN AA, revealed that writer was called to room by Certified Nursing Assistant (CNA) stating the resident has a new wound issue. Writer observed baseball size wound with black eschar covering. Wound doctor (Physician FF) was asked to further assess patient. Wound debrided per wound doctor. New order for Dakins solution 0.25% and air mattress. Responsible Party (RP) notified. Wound now covered with dressing. Review of the Wound Physician (Physician FF) notes dated [DATE] revealed the resident has a Stage IV pressure ulcer to his sacrum which measured 10X5X2 cm with thick adherent devitalized necrotic tissue 100%. Surgical excisional debridement procedure completed. Treatment: Dakins Solution one daily and discontinue [MEDICATION NAME] dressing. Review of the (MONTH) 2019 TAR revealed no evidence the sacral wound treatment for [REDACTED]. Further review of the (MONTH) 2019 TAR to clean wound with normal saline, blot dry, pack wound with Dakins moistened gauze, cover with dry dressing and secure with tape daily revealed that no evidence that this treatment was completed [DATE] through [DATE]. Review of the (MONTH) 2019 TAR revealed the treatment was completed on [DATE]. Record review of the hospital History and Physical dated [DATE] revealed had a left AKA on [DATE] and a revision on [DATE]. The resident has altered mental status. The resident reportedly missed several follow up appointment with vascular to the AKA survey in January. He required a revision to the surgical wound with a wound vac placed with instructions to be changed three times per week. The SNF (facility) SW called the patient's Primary Care Provider (PCP), who upon assessment feared the patient has become septic so the patient was sent to the Emergency Center (EC). The patient's left AKA site appears to be infected, likely gangrenous, bone is visible, eschar and malodorous. The resident temperature is 100.4 degrees. The resident's weight was 52 kilograms (114.4 pounds). Assessment:[MEDICAL CONDITION] due to wound infection, left AKA site infection-likely wet gangrene, acute or chronic [MEDICAL CONDITION]-Hgb 6.0, dehydration with electrolyte derangement-[DIAGNOSES REDACTED], [MEDICAL CONDITION], [DIAGNOSES REDACTED], elevated BUN (Blood, Urea, Nitrogen), severe protein calorie malnutrition. Record review of Consultation report by Physician EE dated [DATE] revealed that the resident was not transported for follow up care on [DATE] and that the facility declined offer for appointment on [DATE] secondary to transportation. Today the SNF Social Worker (SW) called to ask for resident to be send at the instructions of Physician CC for fear the resident was becoming septic. NP DD called Physician CC to ask for the patient to be sent to the EC for evaluation. Plan for Operation tomorrow for left AKA revision. Review of the Operative Report dated [DATE] revealed that four additional inches were removed from the resident left stump in order to reach viable tissue. Plan: Wound check in ,[DATE] weeks. I will check [MEDICATION NAME] level to assess the patient's nutritional status. The patient appears to have been neglected at the home (facility) so close observation of this wound is paramount. Record review of the hospital records revealed the resident's [MEDICATION NAME] on [DATE] was 1.3 (3XXX,[DATE].8) and the pre-[MEDICATION NAME] was 5 (,[DATE]) on the same day. Record review of a hospital Physician Consultation dated [DATE], revealed that the hospital team was concerned that the resident may have perianal abcess with a Computerized [NAME]ography (CT) scan performed on [DATE]. The CT scan showed an intersphinceteric perianal fistula, which was draining stool. Also noted was chronic diarrhea. Surgery was consulted. Plan: debridement of the sacral decubitus ulcer and fistulotomy. Review of the Operative Report dated [DATE], revealed that a laparscopic diverting loop [MEDICAL CONDITION] was performed for treatment of [REDACTED]. Review of the hospital Discharge Summary dated [DATE], revealed the resident developed a code blue (arrest) at 7:00 a.m. He received ACLS (Advanced Cardiac Life Support) for 20 minutes plus and reportedly lost pulse twice in the interim. Due to poor prognosis and prolonged attempt to resuscitate, ACLS efforts were called at 7:31 a.m. Assessment:[MEDICAL CONDITION] due to left AKA stump wound infection, wet gangrene, severe protein calorie malnutrition, low [MEDICATION NAME] and pre-[MEDICATION NAME]. Record review of the Physician EE's office notes dated [DATE] at 12:33 p.m. revealed that the facility SW called the office requesting an appointment for R#1 today. She states that something is going on in the resident groin that has the wound vac and the patient needs to see the doctor ASAP (as soon as possible). She states they are concerned he may be septic, states he has fever and chills for ,[DATE] days, wound smells awful and he has been talking out of his head the past few days. She states the attending Physician at the facility (Physician CC) will not write orders to have the patient sent to the EC for evaluation, but states the patient needs to go to Physician EE's office for evaluation. She states the wound care nurse walked out of the facility last week and the nurses on the floor have been treating this patient's wound the best they know how. She mentions that Physician FF debrided an area on the patient's back last Thursday. Action Taken: SW was informed that Physician EE is not n the office today, that his office day is on Monday's. Told her the patient had an appointment on [DATE] that the patient was a no show and last Friday when they were rescheduling the resident's appointment to [DATE], the facility refused due to needing three days for transport. States that she made arrangements with transport company for [DATE] but they never showed up and this happens frequently with the transportation company. Made her aware patient needs to go to the EC for evaluation and that Physician EE can see the resident in the EC. She states that Physician CC refuses to write the order and states that Physician EE needs to write the order. The NP DD made contact with Physician CC and the resident is coming to the EC. An interview on [DATE] at 9:46 a.m. with Licensed Practical Nurse (LPN) AA revealed that she received an order on [DATE] to send R#1 to the hospital. The current Director of Nursing (DON) was the person who removed the [DEVICE] on [DATE]. The DON removed the wound vac but was unable to reconnect the [DEVICE] to R#1 stump. The treatment nurse had already quit and there were no other nurse in the building who had been trained on the wound vac or were familiar with the wound vac. She further states that after the treatment nurse quit, the wound vac dressings were not change. She was not aware if the Physician (CC) was aware or knew that no one was doing the [DEVICE] dressings changes. She further revealed that the nurses did not receive training for the wound vac. She further revealed that R#1 had missed at least four of his appointments with the surgeon (Physician EE). An interview on [DATE] at 4:10 p.m. the Physician CC revealed that the R#1 had developed a wound on his foot (left). He referred the resident to the vascular clinic. Resident had severe [MEDICAL CONDITIONS] and in (MONTH) the resident had an above the knee amputation (AKA). The amputation deteriorated and resident had a [DEVICE] place. He stated that the facility has had a lot of turn over. He further revealed that he could not remember when he gave the order to stop the [DEVICE], but he gave an order for [REDACTED]. He was aware that the resident had missed several appointments and that he called transportation services, himself, to complain although he could provide no documentation as to who he called or when he called the transportation company. Physician CC revealed that R#1 died in the hospital and he did not know the cause of death. An interview with the Administrator on [DATE] at 4:56 p.m. revealed that the DON was terminated on [DATE]. The Assistant DON (ADON) and the Treatment Nurse left without notice. The ADON resigned without notice on [DATE] and the Treatment Nurse resigned without notice on [DATE] although her last day working at the facility was [DATE]. They utilized agency nurses at that point. An interview on [DATE] at 7:55 a.m. with Nurse Practitioner (NP) DD, who is employed by the Vascular Surgeon, revealed that an amputation normally heals without having to do a [DEVICE]. When an amputation is not healing, then the [DEVICE] is placed to promote healing which needs to be changed every third day. She revealed that the resident has had missed appointments for follow up visits. She was aware that Physician CC went to see the resident at the facility on [DATE]. On [DATE], Physician CC had to be asked to send resident to the Emergency Center (EC). The resident's stump was terrible, odorous and could smell the odor from the ER room. R#1 presented to the ER with bone exposed, deteriorated at the suture line and up to the inner leg. The resident had to be taken to surgery to removed four (4) inches from the remaining stump to reach viable tissue. The bottom line the resident had develop an anal fistula, at the Stage IV pressure ulcer area, that was constantly leaking stool and was contaminating the left stump wound. The stump had significantly deteriorated from the last time it was seen by Physician EE. During an interview on [DATE] at 2:02 p.m. Physician FF revealed that when she came to the facility to assessment the R#1 sacral wound on [DATE], that the nurse wanted her to look at R#1's surgical stump. She told the nurse that the resident was post-op and was still under the supervision of the surgeon for at least three months and she could not treat the surgical wound. She was aware the wound had an odor and suggested the nurse contact the surgeon (Physician EE). A subsequent interview on [DATE] at 2:58 p.m. Physician CC revealed that on [DATE] he saw the resident and started the resident on oral [MEDICATION NAME] until the resident could be seen by the surgeon on [DATE]. He could not recall if there was a strong odor when seeing the resident on this visit. The resident missed that appointment due to transportation. On [DATE], he gave the order to send resident to emergency room (ER) for evaluation. Physician EE, the surgeon, was on call that evening. An interview with the Administrator on [DATE] at 3:51 p.m. revealed that the previous DON was responsible for training staff and agency nurses. He revealed that the Agency was responsible for training agency nurses, although the staff nurses were responsible for showing the agency nurses how the facility does things at this facility. He revealed not having knowledge that weekly wound assessment and wound treatments were not being done. An interview on [DATE] at 4:47 p.m. with R#2, who was R#1's roommate, revealed that the R#1 stump became infected and the odor was bad. He had complained to staff and the resident was moved to another room. An interview with the Administrator on [DATE] at 4:21 p.m. revealed that morning meetings had begun, again, on [DATE] and was held to discuss issues pertaining to the facility. The clinical meetings were held by the DON and that he did not attend the clinical meetings. He did get a summary of the number of people who were discussed but not their names. An interview on [DATE] at 9:43 a.m. with Certified Nursing Assistant (CNA) QQ revealed that her first day at the facility was [DATE] and she was assigned to R#1. She was providing ADL (activities of daily living) care to the resident and found a wound on his sacral area the size of an apple. She reported it to an agency nurse, who stated this had not been reported to her. She revealed that the Wound doctor (Physician FF) was in the building and the agency nurse asked her to see the resident's wound. She further revealed that R#1 had been in a multi-bed ward but was moved due to his roommates complaining about the odor. She further stated there hadn't been a wound nurse for a couple of weeks. She revealed that the resident had gone from feeding himself to needing assistance to eat. She further revealed that she had reported that the resident wasn't eating to the agency nurses and to LPN AA. An interview with R#8 on [DATE] at 11:58 a.m, a former roommate of R#1 (who was in a multiple bed ward at that time), revealed that the R#1 had a smell and some sort of machine to this leg. The smell was weird and strong. He had reported it to one of the nurses then R#1 was moved to another room. An interview on [DATE] at 10:14 a.m. with CNA RR who revealed that about one to two weeks after R#1 returned from the revision, he became delusional. He was constantly turning on his call light then saying outlandish things such as he needed to get up and walk. The smell from him was like something rotten, decaying. The smell was so bad that you needed to open the windows. The treatment nurse would spray a disinfecting spray in the room. The wound started smelling after the wound vac was placed and the contents in the vacuum container looked like pus. He was moved out of the ward to another room due to smell and then he stopped eating. She had reported it to LPN AA who told them just to give him health shakes but even with assistance he wouldn't eat much. She revealed that on [DATE] that LPN AA and the agency nurse were working with his wound vac, attempting to figure out what to do and it wasn't working. She further revealed that the resident had a sunken look, his lips were dry and cracked. An interview on [DATE] at 12:04 p.m. with the current DON revealed that the wound suction canister was ¾ full. This was the first time he actually seen the wound, which was on [DATE]. He further stated that Physician CC was dragging his feet about sending the R#1 to the hospital. We (SW) called the vascular clinic to get assist with sending the resident out. An interview with the SW on [DATE] at 2:00 p.m. revealed that she had contacted Physician EE's office seeking help for R#1. She stated that Physician CC would not give an order to send the resident to the hospital and she was very concerned about the resident. She further stated that staff had been trying to get Physician CC to send the resident to the ER because he was getting worse, his wound smelled so badly, and the resident was becoming more confused. She confirmed that the resident was transferred to a semi-private room, without a roommate, on [DATE] due to complaints of the odor by the resident's roommates. The SW stated she may have mentioned to the Administrator regarding Physician CC refusing to send the resident to the ER but since he was not clinical, she may not have gotten into the details about the situation. Cross refer F684, F686, F692, F835, F837, F841, and F867

Based on record review, observation, review of the facility policy and procedure titled Skin Care Guideline and staff interview the facility failed to perform weekly skin checks to identify breakdown timely and then failed to consistently assess the status of the developing sacral pressure ulcer until it was a Stage IV which required debridement for one resident (R#1). The facility also failed to perform weekly skin checks and consistently assess the status of the sacral pressure ulcer for (R#3, R#4) three of nine sampled residents. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order for [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the Skin Care Guideline Statement of Purpose: To ensure that each resident will be assessed for possible skin breakdown and to ensure that preventative and/or restorative measures are implemented as needed. The Physician will be notified of any pressure sore condition; including the occurrence of drainage or signs of infection, or failure of progress of treatment and intention to change treatment. The Physician will be notified of presence of eschar in a grade III or IV ulcer. Guidelines: It is the practice of this facility to provide Head-to-Toe skin assessments as part of this facility' prevention program. Procedure: the procedure for providing a Head-to-Toe assessment include but is not limed to the following: 1. Each resident is provided a head to toe assessment during the delivery of bath by their assigned CNA 2. Each moderate and low risk resident is provided a head to toe skin assessment by a licensed nurse per schedule. 3. Any resident receiving wound care or is at high risk, the treatment nurse or RN/LPN will do a head to toe skin assessment weekly per schedule. 10. The treatment nurse is responsible for each day for: f. Documenting in treatment notes after assessing, notifying MD and family and initiating the treatment. Protocol for Stage 1 Pressure Ulcer Care Interventions 5. Treatment Nurse or designee to assess weekly and document progress. Protocol for Stage IV Pressure Ulcer Care Interventions 4. Treatment Nurse or designee to assess weekly and document progress. 6. Assess for pain related to pressure ulcer during turning, dressing changes and debridement. Nutritional Support 1. Nutritional Assessment 2. Supplement vitamin C, 500 milligrams (mg) by mouth every day, Zinc Sulfate 220 mg by mouth if proven deficient and multivitamins every day 6. Weights monitored for weight loss or gain either weekly or monthly. 1. Review of the Admission Record and the [DIAGNOSES REDACTED].#1 had the following [DIAGNOSES REDACTED]. Review of the Braden Scale for Predicting Pressure Sore Risk dated [DATE] revealed R#1 had a score of 14 indicating moderate risk. Review of the R#1 care plan, not dated, revealed that he was at risk for alteration in skin integrity related to [DIAGNOSES REDACTED]. The interventions were treatments as ordered; encourage and assist with adequate nutrition intake and notify the Physician as needed. However, the facility failed to develop and implement a care plan for R#1 sacral wound. The sacral wound was identified on [DATE] as a stage 1 and by [DATE] had deteriorated to a Stage IV. There were no interventions identified to prevent further breakdown or to promote the healing of the sacral wound. Review of nutritional care plan, not dated, revealed that R#1 was at risk for alteration in nutrition related to the need for a therapeutic diet and poor dental status; resident refuses to be weighed without his prosthesis. The resident goes to the dining room for meals. The interventions noted were Registered Dietitian (RD) consult as needed; serve diet as ordered; honoring preferences and offering substitutes as appropriate; notify the Physician as needed; and offer supplement shake at lunch. Record review of the Restorative Certified Nursing Assistant (CNA) paper copy of the resident's weights revealed the resident had a 11% weight loss between [DATE] and [DATE] and a 10.5% weight loss between [DATE] and [DATE] for a total of 20% weight loss in 60 days. There were no interventions to address the significant weight loss for the resident. Review of Progress Notes dated [DATE] revealed that the resident was noted to have a Stage I pressure ulcer to the sacrum. Record review of a Progress Note, dated [DATE] at 3:05 a.m., revealed that the resident arrived at the facility on [DATE] at 7:00 p.m., in a wheelchair, via transportation. The resident had open areas to sacral area which were cleaned with normal saline, applied ointment and covered with a dressing. There is no evidence of wound notes to describe the sacral wound or measurements. Record review of a Dietitian Progress Note, dated [DATE], revealed there was no Braden scale on chart. Resident on No Added Salt (NAS) diet regular texture, can feed self and consumes ,[DATE]% of the food. He does have wound on Left stump, Stage I on sacrum. He is on Health shakes, Multi-dose vitamins (MDV) and Pro-stat to promote wound healing. He does have bilateral AKA. No new weight on chart at this date. Could not finish nutritional assessment. Review of the Bath/Shower Report Sheets dated [DATE], and [DATE] revealed R#1 skin was intact. On [DATE] and [DATE], the bath sheet did not indicate the resident skin status. Whereas, it was identified that R#1 was noted to have a stage 1 on [DATE] and on [DATE] R#1 was identified as a stage II. There was no other bath sheet available after [DATE]. Review of the Wound Physician (Physician FF) Notes dated [DATE] revealed the resident had a Stage II pressure ulcer to the sacrum. treatment plan: [REDACTED]. Record review of a Progress Note, dated [DATE] signed by Licensed Practical Nurse (LPN) AA, revealed that writer was called to room by Certified Nursing Assistant (CNA) stating the resident has a new wound issue. Writer observed baseball size wound with black eschar covering. Wound doctor was asked to further assess patient. Wound debrided per wound doctor. New order for Dakins solution 0.25% and air mattress. Responsible Party (RP) notified. Wound now covered with dressing. Review of the Wound Physician (Physician FF) notes dated [DATE] revealed the resident has a Stage IV pressure ulcer to his sacrum which measured 10 X 5 X 2 centimeters (cm) with thick adherent devitalized necrotic tissue 100%. Surgical excisional debridement procedure completed. Treatment: Dakins Solution one daily and discontinue [MEDICATION NAME] dressing. Review of the (MONTH) 2019 Treatment Administration Record (TAR) revealed no evidence the sacral wound treatment for [REDACTED]. Further review of the (MONTH) 2019 TAR, for a new Physician's order dated [DATE], to clean wound with normal saline, blot dry, pack wound with Dakins moistened gauze, cover with dry dressing and secure with tape daily revealed that no evidence that this treatment was completed [DATE] through [DATE]. Review of the (MONTH) 2019 TAR revealed the treatment was completed on [DATE]. There was no evidence that the facility had conducted weekly skin assessments for R#1 or head to toe assessment upon readmission on [DATE] per the facility's policy. Record review of a hospital Physician Consultation record dated [DATE], revealed that the hospital team was concerned that the resident may have perianal abscess with a CT (Computerized [NAME]ography) scan performed on [DATE]. The CT scan showed an intersphinceteric perianal fistula, which was draining stool. Also noted was a chronic diarrhea. Surgery was consulted. Plan: debridement of the sacral decubitus ulcer and fistulotomy. Review of the Operative Report dated [DATE], revealed that a laparoscopic diverting loop [MEDICAL CONDITION] was performed for treatment of [REDACTED]. An interview with the Administrator on [DATE] at 4:56 p.m. revealed that the DON was terminated on [DATE]. The Assistant DON (ADON) and the Treatment Nurse left without notice. The ADON resigned without notice on [DATE] and the Treatment Nurse resigned without notice on [DATE] although her last day working at the facility was [DATE]. They utilized agency nurses thereafter. An interview on [DATE] at 9:43 a.m. with CNA QQ revealed that her first day at the facility was [DATE] and she was assigned to R#1. She was giving ADL (activities of daily living) care to the resident and found a wound on his sacral area the size of an apple. She reported it to an agency nurse, who stated this had not been reported to her. She revealed that the Wound doctor was in the building and the agency nurse asked her to see the resident's wound. She further stated there hadn't been a wound nurse for a couple of weeks. She revealed that the resident had gone from feeding himself to needed assistance to eat and was only taking sips of fluid at this time. She further revealed that she had reported that the resident wasn't eating not eating to agency nurses and to LPN AA. Cross refer to F600 2. Review of the Admission Record dated [DATE] revealed that R#3 is noted to have the following [DIAGNOSES REDACTED]. An observation on [DATE] at 7:42 a.m. of the dressing change with LPN UU revealed the resident was lying on an air flow mattress and has on bilateral heel protectors. LPN UU assessed the resident for pain, then wash her hands, donned gloves and removed the old, undated, wound dressing. The wound bed is observed to have 40% reddish granulations, 60% pinkish granulation, the outer edge of the wound bed has white edges. She obtained measurements, the wound measurements 3.5 x 3.0 x 0.6 cm. She removed her gloves, sanitized her hands, and donned gloves. The wound bed is cleansed with normal saline using the inner-outer technique. Skin prep is applied to the surrounding intact skin. She then placed moistened gauze with Dakins solution to the wound bed, and cover with adhesive dressing pre-labeled with the date. Observed both heels, they were dry and intact. Review of the Braden Scale for Predicting Pressure Sore Risks dated [DATE] revealed score of 17 indicating at risk. Review of the (MONTH) 2019 TAR revealed the following missing sacral wound treatments on [DATE], [DATE], [DATE], [DATE] and [DATE] as indicated by no initials. Review of the (MONTH) 2019 TAR revealed missing sacral wound treatments on ,[DATE], ,[DATE], ,[DATE], and [DATE] as indicated by no initials. Review of the (MONTH) 2019 TAR revealed missing sacral wound treatments on ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], ,[DATE], and [DATE] as indicated by no initials. Review of the (MONTH) 2019 TAR revealed missing sacral wound treatments on ,[DATE]/, ,[DATE], ,[DATE], and ,[DATE] as indicated by no initials. Review of the (MONTH) 2019 TAR revealed missing sacral wound treatment on ,[DATE], ,[DATE], and [DATE] as indicated by no initials. Review of the Wound-Weekly Observation Tool revealed that the facility was unable to produce documentation of weekly wound assessment or measurements from [DATE] through [DATE]. Review of the consulting Wound Physician (Physician FF) reports dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] revealed that R#3 sacral wound was being assessed and followed every two weeks by the wound physician. 3. Review of the Admission Record revealed that R#4 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. Review of the Braden Scale For Predicting Pressure Sore Risks dated [DATE] revealed a score of 16 indicating at risk Review of the Progress Notes Skin/Wound Notes, dated [DATE] and signed by the former Treatment Nurse, revealed the resident was noted with excoriation and redness to sacrum. Treatment order was a wedge in place. Review of the Progress Notes, dated [DATE] and signed by the former Treatment Nurse, revealed the resident has a stage 2 pressure area to sacrum. Resident has been added to the wound program. Interventions low air flow mattress, multivitamins and Pro-Stat liquid. Review of the Progress Notes Skin/Wound Notes, dated [DATE] and signed by the former Treatment Nurse, revealed resident sacral wound has gotten worse. Wound consultant Physician FF to assess on next visit, family notified and will continue to monitor. Review of the Progress Notes Skin/Wound Notes, dated [DATE] and signed by the former Treatment Nurse, revealed wound consultant physician visited and assess resident's wound to sacrum. Resident wound is stage IV. The consultant wound physician performed debridement to area at bedside today. Review of the Progress Notes Skin/Wound Notes, dated [DATE] and signed by the former Treatment Nurse, revealed resident wound continues at Stage 4 with strong odor, yellowish slough and moderate drainage. The consultant wound Physician performed debridement to area at bedside today. She recommended resident be sent to hospital for further operative debridement and IV antibiotics. The attending Physician XX spoke with the consultant wound physician (Physician FF) discussed the recommendations. The attending Physician suggested that resident be referred to another wound Physician for wound debridement at a wound care center. The previous treatment nurse is waiting response from the wound care office. Review of the Progress Notes Skin/Wound Notes, dated [DATE] and signed by the former Treatment Nurse, revealed resident is being treated for [REDACTED]. The treatment nurse noted that she will continue to monitor. Review of the (MONTH) 2019 TAR revealed resident did not receive any barrier cream to sacrum and peri area after each episode of incontinence. A new order for clean sacrum with normal saline, pat dry, apply hydrogel, cover with dry dressing daily for wound care with a start date of [DATE] and a stop date of [DATE], revealed no evidence of dressing change on [DATE] and [DATE]. Review of the (MONTH) 2019 TAR revealed an order for [REDACTED]. Review of the (MONTH) TAR 2019 for the sacrum remain with Dakin's solution 0.25% to sacrum topically every day shift starting on [DATE] through (MONTH) 19, 2019 revealed missing treatments for [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Review of the (MONTH) TAR the sacrum wound order continued to for Dakin's solution 0.25% to sacrum topically every day shift continuing through [DATE] revealed missing treatments on [DATE], [DATE], [DATE], and [DATE]. Review of the Skin Observation Tool dated [DATE] and [DATE] revealed sacrum with pressure. No measurements and no other skin documentation, except for the Wound Physician's notes. During an interview on [DATE] at 4:56 p.m. the Administrator revealed the previous Director of Nursing (DON) was terminated on [DATE]. The Assistant Director of Nursing (ADON) resigned without notice on [DATE] and treatment nurse left without notice on [DATE] although she did not work on the [DATE]. Agency nurses were utilized until he could hire a new DON and new treatment nurse. The new treatment nurse started about ,[DATE] weeks ago. He stated that he hired two Registered Nurses (RN) to do weekend wounds alternating the weekends. The plan is to keep the RN as supervisor on weekend. They would only work a medication cart for unforeseen call outs. If the RN supervisors were working on the cart each nurse would be responsible for their assigned residents' wounds treatments.

Based on record review, review of hospital records, review of the facility Weight Policy and Procedure(no date) and Change of Condition policy (updated ,[DATE]) and staff interviews, the facility failed to notify the Physician and Registered Dietician of a significant weight loss for one resident (R#1) who had a 20 percent (%) loss in two months. The facility also failed to notify the Vascular Surgeon of the deterioration of the surgical wound for that same resident (R#1) who was sent to the hospital and expired due to complications [MEDICAL CONDITION] from his wound of a sample of nine residents reviewed for a change in condition. An Abbreviated/Partial Extended Survey investigating complaint GA 880 and GA 960 was initiated on [DATE] and concluded on [DATE]. Complaint GA 880 was substantiated and GA 960 was partially substantiated with deficiencies. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Resident Form, the facility census on [DATE] was 76. On [DATE], a determination was made that a situation in which the facility's non-compliance with one or more requirements of participation had caused or had the likelihood to cause serious injury, harm, impairment or death to residents. The facility's Social Services Director was informed of the Immediate Jeopardy on [DATE] at 1:31 p.m. The Administrator, owner and other members of the Governing Body were unavailable and had designated the Social Services Director as the facility representative. The non-compliance related to the Immediate Jeopardy was identified to have existed on [DATE]. Immediate Jeopardy is outlined as follows: R#1 had an above the knee amputation (AKA) of his left leg on [DATE] and was readmitted to the facility on [DATE] with surgical wound treatment orders to be done daily. There was no evidence of treatments being performed on [DATE], [DATE], [DATE], [DATE] and [DATE]. The resident was sent to the hospital on [DATE] for a surgical wound revision due to his non-healing left AKA. The Operative report dated [DATE] revealed incision and revision of the left AKA to remove necrotic skin and subcutaneous fat and placement of a [DEVICE]-Assisted Closure (vac) dressing to facilitate healing of the surgical wound. R#1 was readmitted to the facility on [DATE] with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room on [DATE], without a roommate, due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the Surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending physician (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The Surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. In addition, R#1 had a weight of 133 pounds (lbs.) on [DATE] after readmission for his left AKA. The resident's weight on [DATE] was 106 lbs, a 20 percent (%) weight loss in two months. Review of the ,[DATE] intake records revealed that the resident's intake was decreasing beginning in late ,[DATE]. Beginning on [DATE] the resident's meal intake was consistently between ,[DATE]% with frequent refusals. There was no indication that the Registered Dietician (RD) had been consulted about the resident's weight loss or non-healing surgical wound so that interventions could be developed and implemented to prevent further weight loss and promote wound healing. R#1 expired on [DATE] due to complications [MEDICAL CONDITION] from his wound. Immediate Jeopardy was identified on [DATE] and determined to exist on [DATE] in the areas of 42 CFR 483.10(g)(14)(i)-(iv)(15) Notification of Changes, F580; 42 CFR 483.12 (a)(1) Abuse and Neglect, F600; 42 CFR 483.21 (b)(1) Development/Implement Comprehensive Care Plan, F656; 42 CFR 483.25 Quality of Care, F684; 42 CFR 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; 42 CFR 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692; 42 CFR 483.70 Administration, F835; 42 CFR 483.70(d)(1)(2)(ii-iii) Governing Body, F837; 42 CFR 483.70(h)(2) Responsibilities of Medical Director, F841; 42 CFR 483.75(g)(2)(ii) QAPI/QAA Improvement Activities, F867. F580, F600, F656, F684, F686, F692 were at a Scope and Severity (S/S) of a J. F835, F837, F841 and F867 were at a Scope and Severity (S/S) of [MI] Additionally, Substandard Quality of Care was identified at 42 CFR 483.12(a)(1) Abuse and Neglect, F600; 483.25 Quality of Care, F684; 483.25(b)(1) Treatment/Services to Prevent/Heal Pressure Ulcers, F686; and 483.25(g)(1) Nutrition/Hydration Status Maintenance, F692. At the time of exit on [DATE], an acceptable Immediate Jeopardy Removal Plan had not been received therefore the Immediate Jeopardy remains on going. Findings include: Review of the facility Weight Policy and Procedure (no date) revealed that residents were weighed a minimum of two times each month. The Food and Hydration Aide weighed residents within 24 hours of admission to the facility, then weekly for 4 weeks and twice monthly thereafter. Weight changes were calculated within 48 hours of obtaining body weights through the use of a computer program. The Food and Hydration Aide notified the Registered Dietician (RD) of residents with a significant weight change via the Weight, Food and Hydration Notification form. The RD assessed each resident with a significant weight change, made appropriate recommendations to physicians and updated the resident's plan of care. Review of the facility Change of Condition policy (revised ,[DATE]) revealed that any staff member who noticed a resident status change would immediately notify the appropriate licensed personnel. After assessing the resident, the licensed personnel would contact the Physician immediately regarding the status change. When the Physician was unavailable, the alternate would be contacted. Notification of the appropriate individuals was to be documented in the medical record and the 24 hour report and followed for 72 hours. Life threatening situations may warrant immediate transfer to the hospital. The Director of Nursing (DON) would be kept informed of all condition changes and would share those with the Administrator on a daily basis. Review of the Admission Record, dated [DATE], and the [DIAGNOSES REDACTED].#1 (R#1) had the following [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) for (MONTH) 2019 revealed that there was no evidence that the treatment had been completed on [DATE], [DATE], [DATE], [DATE], or [DATE]. Record review revealed a change in the Physician Order, from the surgeon (Physician EE), on [DATE] to Santyl ointment, apply to left stump topically every, day shift for wound. Clean left stump with normal saline, pat dry, apply on ointment to eschar and left edge, wet to dry in the middle of wound, cover with dry dressing daily. Record review of Progress Notes dated [DATE] revealed that the resident stump wound was declining, had an odor, which the resident stated makes him sick on his stomach. Resident has a low-grade fever. Treatment to left stump ongoing. There was no evidence that Physician CC was notified of the wound decline. Review of the Hospital discharge order sheet, dated [DATE], He has a special matrix dressing inside. Wound vac should be set at 75. DO NOT remove the vaseline gauze and dressing beneath it. Wound care nurse to change the wound vac on MWF (Monday, Wednesday, Friday). Please send dressing change supplies to the office on (MONTH) 25, 2019 for wound vac changes. R#1 was readmitted to the facility on [DATE] (Saturday) with a Physician order [REDACTED]. The resident's wound vac dressing was changed on [DATE], [DATE], [DATE] and [DATE] but, was not changed thereafter, as the wound nurse resigned on [DATE]. No licensed nursing staff knew how to change the wound vac dressing. The resident was transferred to a semi-private room, on [DATE], without a roommate due to the complaints of the foul smell from the wound. Review of the Vascular Surgeon's (Physician EE) office notes dated [DATE] revealed that the Social Worker (SW) had contacted the surgeon's office saying that R#1 needed an appointment today. The SW was documented as saying the resident had fever, the wound smelled very badly and that the attending Physician CC (and Medical Director) for R#1 would not give an order to send the resident to the hospital. The surgeon spoke with the facility Medical Director and an order was given to send R#1 to the emergency room (ER). The resident was sent to theER on [DATE] and had a second surgical revision of his left AKA. An interview with the Administrator on [DATE] at 4:56 p.m. revealed that the Social Worker, who is a former Ombudsman and a former Administrator (without an active license) is responsible for arranging transportation for the residents. The Administrator states that the facility has had difficulty with the transportation company that may not send appropriate transportation for the residents. An interview on [DATE] at 4:47 p.m. with Physician EE (Vascular Surgeon), revealed that he placed the [DEVICE] to promote the healing of R#1 surgical site. When asked what effect if any, if the [DEVICE] dressing was not change, he stated that not changing the sponge every 3rd day, would prevent seeing signs of infection and wound deteriorating. The [DATE] was a critical appointment to access the progress of healing, but the resident was a no show for this appointment and the facility declined the appointment for [DATE]. The facility had not communicated with him on the condition of the wound nor was he notified that staff did not know how to change the wound vac. He further revealed that if the facility had contacted him then would have help the facility to facilitate the use of the [DEVICE]. He revealed that the former Treatment Nurse and the facility SW had contacted his office as needed in the past. Review of the facility Monthly Weight Record (which not available in the electronic record) revealed that R#1's weight on [DATE] was 133 pounds, on [DATE] his weight was 118 pounds and on [DATE] was 106 pounds. The (MONTH) to (MONTH) 2019 revealed R#1 had a 11% weight loss; (MONTH) - (MONTH) 2019 was a 10% weight loss; and (MONTH) -[DATE] revealed 20% overall weight loss from the date of returning from the hospital on [DATE] to being readmitted on [DATE] to the hospital. Review of the Progress Notes Nutrition/Dietary Note dated [DATE] revealed this was the only entry for the current year (2019). The Registered Dietitian (RD) noted that R#1 had a wound on his left stump and a stage 1 on his sacrum. It is also, noted that resident was receiving Health Shakes, multivitamins (MVI) and Pro-Stat to promote healing of wounds. He does have bilateral AKA. No new weight on chart at this dated. Could not finish nutritional assessment. Review of the resident's intake record revealed that the resident had begun with poor intake in late (MONTH) 2019 and then throughout (MONTH) 2019 his intake was ,[DATE]% per meal and regularly refused his meals. Review of the Wound doctor (Physician FF) note dated [DATE] revealed the resident now had a Stage IV pressure wound to his sacrum. The wound measured 10X5X2 centimeters with thick adherent devitalized necrotic tissue. The facility could not provide evidence of skin assessments from [DATE] except for the Wound Physician FF's wound notes. During an interview with the RD on [DATE] at 11:04 a.m. revealed that she was not aware that R#1 was not eating and that she received her wound stage from the former treatment nurse. She further stated that she comes to the facility on ce a month and physically sees each resident. When she came in March, the resident was still able to feed himself. The only concern she had at that time, he was a bilateral AKA and that his left AKA was not healing. She had not received information that the resident had developed a Stage IV pressure ulcer or of his weight loss and diminished intake. An interview with Physician CC (Medical Director) on [DATE] at 4:40 p.m. revealed that he could not recall if he had been notified of the weight loss or of the development of a Stage IV pressure ulcer. Physician CC did confirm giving an order on [DATE] for [MEDICATION NAME] and [MEDICATION NAME].