Every finding on record at Brookdale Galleria

Based on observations, interviews, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 8 residents (Resident #1) reviewed for adequate supervision. The facility failed to ensure that Resident #1 received adequate supervision when Resident #1 was able to exit the facility at 1:00am and found by staff on a busy street. An Immediate Jeopardy (IJ) was identified on 3.20.2026. The IJ template was provided to the Administrator on 3.20.2026 at 5:48 p.m. On 3/21/26 at 8:15pm, the Administrator was notified that the IJ was removed; however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible serious injuries, harm and deathThe Findings include:Record review of Resident #1's undated face sheet, revealed Resident #1 was a [AGE] year-old female, who admitted to the facility on [DATE] and discharged on 3/12/26, with a primary diagnosis of Cerebral Infraction (stroke). Upon admission, Resident #1's BIMS dated 3/12/26 revealed she had a score of 7 out of 15 indicating Resident #1 had severe cognitive impairment.Record review of Resident #1's care plan revealed the following:Focus: Resident #1 has an ADL Self Care performance Deficit r/t weakness, deconditioning from recent hospital stay (date initial: 3/9/26; Revision: 3/12/26)Goal: Resident #1 will improve in ADL functional status by the next review date (dated initiated: 3/9/26; target date: 6/7/26)Interventions/Task:Encourage the resident to participate to the extent possible with each interaction (dated initiated: 3/12/26)Encourage the resident to use call bell for assistance (dated initiated: 3/12/26)Explain all procedures/tasks (dated initiated: 3/12/26)Promote dignity by ensuring privacy (dated initiated: 3/12/26)PT OT evaluation and treatment as per MD orders (dated initiated: 3/9/26)Record review of Nursing notes dated 3/12/26 at 2:04 am by RN A stated, Making rounds at 11:00 PM, resident was observed on the bed sleeping. CNA took her vital signs without any changes. Then upon rounds at around 1:00 to 1:15 AM this writer noticed resident was not in bed, checked her bathroom and adjacent rooms, resident was not found, security was alerted writer went through the stairs door in front of her room to search the pool area in the backyard. Resident was not found. Then rider [writer] ran to the front of the building, spoke with one of the security guards who confirmed they let a woman out around 1:20 AM, thinking she's homeless. At that point everyone went to the streets, staff, security to look for resident. Resident was found walking on the road to the right side of the building on the pedestrian walkway. Then brought back into the building. Residents show writer how she walked out of the room through the stairs, to the pool area and a man let her out of the building. Assessment done, no injury observed, denies pain or discomfort. On call, administrator, DON, son and daughter were not notification. Resident is on one-on-one supervision.[sic]Record review of Security guard suspension report dated 3/12/26 revealed he was suspended and received in-sevice on abuse and neglect, elopement, emergency door monitoring, pool monitoring, and unfamiliar person protocol.Record review of Nursing notes dated 3/12/26 at 8:46am by RN A stated, Resident #1's FM voiced concerns that Resident #1 is a flight risk after RN A notified her of Resident#1's elopement incident.Record review of Occupational Therapy evaluation summary dated 3/11/26 revealed, a physical cognitive psychosocial impairment imbalance (a decline in bodily functions and problems with memory), fine motor coordination (loss of coordinated hand movement sometimes described as clumsiness), dexterity and mobility (unable to move around freely).Record review of the following In-Services completed between 3/21/26:Door Monitoring In-service revealed that the Facility has instituted immediate monitoring of the emergency exit doors leading outside to the pool and common areas. There is a staff person assigned at each door of egress, which leads outside near the pool area. There is also a sign in a sign out sheet and no resident visitor or staff shall be allowed to exit unless there is an event of an emergency. Staff who have been assigned to that area will be relieved for breaks and lunches and document on the assigned form.Staff exterior walking rounds and documentation In-service revealed staff hourly rounds in the dog park, pool, dog park gate secured, pool gate secured with staff initials.Walkie Talkie In-Service revealed walkie talkies are to be picked up by charge nurses and checked out at the beginning and returned at the end of each shift. This will enhance communication with security if needed.Emergency Exit and Fire Door Usage revealed that staff must not use these doors unless there is an emergency. Staff must investigate each time an alarm sounds for these doors.Elopement/Missing Resident revealed staff must alert other staff by calling a Code Yellow, skills check quiz for each employee, ensure the elopement Binders are located on the 1st and 2nd Floor nurses' station and at the front desk.Abuse and neglect and its definitions, types, reporting and the abuse coordinator.Unfamiliar person protocol Instant In-service to immediately remind staff of their obligations to identify all persons on the property.Elopement Risk assessment completed 3/12/26 on all residents in the facility.Incident/Accident Reporting Policy effective 03/2009 and last revised 06/2025 revealed the following:Complete an incident report for the following situations:ElopementRecord review of Impromptu QAPI dated 3/12/26 revealed an impromptu meeting regarding resident elopement & Binders, behavior monitoring, swimming pool concerns, and staff assigned at fire door, and egress monitoring 24/7.On 3/17/26 at 10:00 am in an interview with Admin, she said FM packed Resident #1 up the day before (3/11/26) so that she could go to a different rehab that the family felt was best for Resident #1. At 12:55 am rounds were made and at 1:02 am she went to the patio. She stated security spoke with Resident #1 at 1:06 am. She stated the RN was doing rounds while Resident #1 was speaking with Security A. The RN noticed Resident #1 was not in her room. RN A went to stairwell and didn't see anyone. RN came out of stairwell and notified other staff members that the resident was missing. The RN A, LVN A and CNA A, and CNA B proceeded to look in rooms, then to front desk to ask Security if he noticed a female resident in the area and he said, yes. Security stated that he opened the gate in the pool area, allowed Resident #1 inside the front of the building and then escorted her out of the facility. The Admin stated Resident #1 was not on property and was found by nursing staff on the sidewalk (street) walking. Admin stated Resident #1 was fully dressed. Admin stated all facility employees, including security personnel, received in-service training. Admin stated Security was suspended and received additional in-service training.On 3/17/26 at 11:30 am in an interview with Ombudsman who stated she was contacted by FM regarding Resident #1. The Ombudsman stated FM expressed concern that Resident 1 was able to leave the facility without notice at or around 1:30 am, especially when Resident 1 had a cognitive decline. She stated this was a concern and hoped no other residents would be able to get out of the facility without notice.On 3/19/26 at 9:40 am during a telephone interview with FM, she stated Resident 1 had a cognitive decline due to having a stroke and should not have been able to walk out of the facility without notice. FM stated the facility was negligent. FM stated she has been responsible for Resident 1's medical records and made all of her medical decisions since she had the stroke. FM stated the local hospital called her and told her that Resident 1 was a flight risk; however, she assumed this information was in the discharge paperwork from hospital to facility. She stated she was now aware that the local hospital did not add this information to the discharge instructions to the facility. FM stated due to having a stroke, Resident #1 could not order her own meals, make a phone call or get out of bed without assistance as a result of fall risk. FM stated she received a call from the facility at 1:45 am and was informed Resident #1 had eloped, but she was returned to the facility unharmed. FM also stated she was informed that Resident 1 was able to leave because the security guard thought she was homeless and had somehow gotten into the recreation area of the facility. FM stated Resident 1 was wearing a fall risk bracelet, and a stick on heart monitor where the cords were hanging out of the sleeve of her shirt and she should not have been mistaken for being homeless. FM also stated her mother could have drowned because she had full access to the pool and is unable to swim along with being in a dangerous situation on the streets at 1:00 am.On 3/19/26 at 10:13 am during an interview with Speech Therapist she stated according to the treatment notes, Resident 1 required verbal and instructional notes during the initial treatment consult. In other words, she stated Resident needed staff to repeat instructions multiple times and staff would even have to draw pictures. She stated Resident #1 understood verbal instructions 30% of the time and staff would have to repeat and draw pictures 70% of the time. She stated Resident 1 had a cognitive communication deficit. She stated Resident 1 was not always oriented to person, place and time. She stated Resident 1 could not tell you where home was, her address, the date or time.On 3/19/26 at 11:34 am during an interview with Health Information Specialist who stated he completed the admissions document agreement with Resident #1. Health Information Specialist stated he did not notice any altered mental status; however, noticed that all the questions were being answered by FM. Health Information Specialist stated after the end of the admissions interview, he did not ask questions to determine if Resident #11 was oriented to person, place and or time. He stated he just required an electronic signature, which he signed by receiving permission from FM. Health Information Specialist stated the next day after Resident #1 was admitted to the facility, he completed room rounds and spoke with Resident #1 to see if she had any concerns. Health Information Specialist stated he could not remember if Resident #1 had any concerns or complaints. On 3/19/26 at 11:45 am during a telephone interview with Security Guard, he stated he was doing rounds and noticed Resident 1 outside in the swimming pool area. He stated she approached the gate that has to be opened by a security guard to get to the bistro area, which will then allow her to exit the facility from the front door. Security Guard stated Resident 1 was unable to open the gate, so Security Guard opened the gate for her. Security Guard stated he asked how did she get to that area and Resident 1 responded, she came through the backdoor (which is in the garage area and where homeless people enter). Security Guard stated he was thinking Resident 1 was homeless, so he opened the gate and led her out of the facility. Security Guard stated Resident 1 never said anything else. Security Guard stated Resident 1 did not look confused. He stated he did not ask Resident 1 what her name was or any other identifying information. Security Guard stated he did not call any nursing staff on the residents' floor and ask or notify any staff members that a resident was in the area. Security Guard stated after leading Resident #1 out of the front door a CNA came to the front desk and asked if he had noticed a resident wearing a pink sweater in the area and he told CNA that a lady dressed like that just left out of the front door. The CNA informed him that that was a resident and not a homeless person. Security Guard stated he, another security guard, CNA and nurses ran out of the front door to locate Resident 1 and return her to the facility. Security Guard stated this event occurred around 1:10am - 1:15am. Security Guard stated Resident 1 did not have any identifying bracelets or clothing that would make him assume that she was a Resident. Security Guard stated since the incident, he believes he should have asked more questions. On 3/19/26 at 1:23 pm in a telephone interview with CNA A she stated she completed vitals on Resident #1 when she arrived on her shift around 11:00pm. She stated she went to supply room in the basement area around or close to 1:00 am to get supplies, which took approximately 5 minutes. She stated she then had to go to the 6th floor to get additional supplies, which was now a little after 1:00 am. CNA A stated once she returned to 1st floor she observed RN on the far end of the floor shouting, Code Yellow to inform them there was an issue with a resident not in their room. She stated she and CNA B immediately went to security and asked if they observed a resident exit the building and was informed by Security Guard that a woman was wandering in the pool area, and she couldn't say what she was doing or where she was going so he escorted her out of the facility. CNA A stated the Security Guard stated Resident 1 looked like a homeless person and stated Resident 1 told him she was homeless. On 3/19/26 at 1:25 pm in a telephone interview with RN A who stated she made rounds at 11:00 pm and Resident #1 was in bed sleeping and shortly afterwards CNA A completed vitals and left the room. RN A stated around 1:05am while making rounds she noticed Resident 1 was not in bed. RN A stated she checked the bathroom in Resident 1's room and other resident rooms as well. RN A stated she checked everywhere on the floor. RN A stated she did not hear an alarm go off on the exit door to the stairwell, but she went to the stairwell and exited in the back area and didn't see Resident 1. RN A went to security and the security guard stated he escorted a lady, who was in the pool area, out the front door because she was homeless. RN A stated she told Security that lady was not homeless that was a resident. RN A stated at this time, she along with other nursing staff proceeded outside and located Resident 1 walking on the sidewalk on the side of the facility's building. RN A stated Resident 1 said she was going home. RN A stated she escorted Resident 1 back inside the facility and completed a head-to-toe assessment and placed Resident 1 on a 1:1 observation until the DON arrived at 8:00 am. She stated she alerted her Administrator, Medical Doctor, RP and DON.On 3/19/26 at 1:32 pm in a telephone interview with LVN A she stated she was on the first floor completing her charting at nurses' station when RN A told her Resident 1 was missing. She stated she immediately began to assist in locating Resident 1. LVN A stated she and other nursing staff went to the front of the building where they encountered Security Guard and was informed that he let a homeless woman out of the building because she was wandering in the pool area. LVN A stated nursing staff informed Security Guard that the woman he encountered was not homeless she was a Resident. On 3/19/26 at 1:40 pm in a telephone interview with CNA B he stated he worked 11pm-7pm. He along with CNA A was informed by RN A that a resident was missing and called Code Yellow (when someone is missing). CNA B stated he and CNA A looked in residents' rooms on the floor and then went to security guard where the two of them were informed there was a resident who he let out of the building because he thought she was homeless. He stated the two of them went outside and did not see Resident #1, then continued to look on the street and observed her walking.On 3/19/26 at 4:28 pm during a follow-up interview with Admin she stated there was an immediate Instant In-Service Training for all staff (nursing and others) including security. Admin stated there are 3 security guards that work 10pm - 6am only. Admin stated during the morning shift (6:00am-2:00pm) the front desk, and concierge personnel arrive in the facility. Admin stated that in-service training for nursing staff, including therapy and dietary, is conducted monthly or prior if there are any incidents. An Immediate Jeopardy (IJ) was identified on 3/20/26. The IJ template was provided to the Admin on 3/20/26 at 5:45 p.m. and a Plan of Removal was requested.The Plan of Removal was approved on 3.21.2026 at 4:50pmReview of the facility's Plan of Removal reflected:Date: 3/20/2026Plan to remove Immediate jeopardyF689- The facility failed to ensure the residents' environment remained free of accident hazards as is possible in residents receiving adequate supervision in the pool area.Upon Resident #1's return to the community a visual resident count was completed, confirming all residents on census were accounted for. RN completed a visual resident count, on 3/12/26, resident total census was referenced on 3/17/26 to compare visual count to assure all residents were accounted for. Resident #1's received a skin assessment with no areas of concern noted. The skin assessment was completed by RN on 3/12/26. RN notified Administrator, residents' physician, Medical Director (Administrator notified), resident's son was left a message, and resident's daughter was spoken to. RN completed skin assessment for Resident #1 with no concerns identified, BIMS reassessed and resident scored 7, elopement risk assessment completed and determined her to be high risk and Resident #1's placed on 1:1 monitor until her discharge to PAM at 3:29 pm. On 3/12/26. Resident #1's is no longer at this facility. Resident #1's care plan was updated to reflect new risks. In addition, all residents' elopement risks were reassessed and BIMSs were reassessed on 3/12/26 with no one identified at risk.On 3/20/2026, an impromptu Quality Assurance Performance Improvement Meeting was completed with the Healthcare Administrator, Executive Director, Medical Director, and Director of Resident Services via telephone. This meeting addressed security monitoring around the pool and dog park areas of the community. Additional actions to increase safety will include re-education to security/concierge staff on making hourly walking rounds on the pool area and the dog park area. Education and implementation of walking round forms to ensure accurate documentation completed on 3/20/26 by the Executive Director and the Healthcare Administrator.Facility's plan to ensure compliance:On 3/20/2026 Healthcare Administrator, and Executive Director begun education on Emergency Exit Usage and Alarm Investigation. No staff is permitted to use emergency exit doors unless there is an emergency. All staff are to investigate each time the alarm is triggered. All staff, not in-serviced on 03/20/2026, will be in-serviced prior to start of their next shift. This will be documented on an in-service sheet. Associates working in the following positions will receive this education, Nurses, nursing assistants, security, maintenance, concierge, administration, dietary servers, cooks, and dietary manager.On 03/20/2026 Healthcare Administrator and Executive Director completed education with all staff on the resident elopement/missing resident, search procedure, proper notification, resident assessments, and resident monitoring. All staff not reeducated 3/20/2026 will be reeducated before the start of their next shift by the Healthcare Administrator/ Executive Director. Skills test for elopement began with staff working 3/20/26. This will be documented on an in-service sheet.On 3/20/26 Healthcare Administrator/Executive Director begun education with all staff on Abuse and Neglect. Definition of abuse, abuse coordinator name, types of abuse, types of neglect, and the importance of timely notification reviewed with staff. Any staff not reeducated on 3/20/2026 will be reeducated before the start of their next shift by Healthcare Administrator/Executive Director. Skills test for abuse and neglect will be completed once per shift.On 3/20/26 Executive Director completed Instant Reeducation with security/concierge staff on initial contact and verification of wandering resident. Security will ask identifying questions (name, where do you live, how they got to the area, etc.), check for any identifying markers, call nurses' stations to verify if individual may have left assigned area, and refer to elopement binder. This will be documented on an in-service sheet. All security/concierge staff will be retrained prior to the start of their next scheduled shift and will not be able to return to duty until retrained.On 03/20/26 all night shift staff were educated by Healthcare Administrator/Executive Director on the following protocol as an additional method of communication between the nursing facility and the front desk, security. All nursing staff and security education will be completed prior to the start of associate's next shift. This will be documented on an in-service sheet:-Walkie talkies will be located and charged at the front concierge desk. On 03/20/26 all night shift staff were educated by Healthcare Administrator/Executive Director.-Walkie talkies are to be carried by at least one security associate and one direct care associate on each floor. On 03/20/26 all night shift staff were educated by Healthcare Administrator/Executive Director-Walkie talkie will be issued (1) to each floor, and signed out at that time, upon the end of shift walkie will be returned to the front concierge desk.On 03/20/26 all night shift staff were educated by Healthcare Administrator/Executive Director on security protocol, unfamiliar persons protocol, abuse and neglect.On 3/20/2026, the Executive Director and Healthcare Administrator provided immediate re-education to all security and concierge staff regarding required safety monitoring protocols. Training included: completion of hourly walking rounds in both the pool and dog park areas, continuous monitoring of the pool area via security cameras, ensuring the camera feed remains visible on the security desk monitor at all times, prompt reporting of any adverse findings or safety concerns to the Director of Resident Services, Executive Director, and Healthcare Administrator, accurate and timely documentation of all walking rounds and observations. This will be documented on an in-service sheet.On 3/20/2026 Executive Director reeducated Healthcare Administrator on the facility abuse policy, elopement policy.On 3/21/2026 Regional Director of Clinical services educated Executive Director and Health Care administrator on Missing resident policy and, swimming pool and spa policy.The Executive Director and Healthcare Administrator will provide ongoing oversight to ensure adherence to established protocols. Any deviations from required procedures will be addressed promptly through corrective action and additional staff training as needed.The facility will place a staff member at the emergency exit door between dog park and pool area to redirect anyone attempting to exit unless there is an active emergency. This staff member will remain in place 24 hours a day until the gate is reassessed on Monday 3/23/26 and an appropriate locking mechanism is in place to prevent access an identified and approved technology company is scheduled for a meeting at 12:00 pm on 3/23/26 with the Administrator, Director of Maintenance, and Executive Director to assess the appropriate locking mechanism for the gate between the dog park and the pool area. Security will complete 1 hour walking rounds on the pool and dog park area. Any adverse findings will be documented and reported to Director Residents Services, Executive Director, and Healthcare Administrator.The policy for the pool area was reviewed on 3/21/26 with no additional updates. Access to the pool area is restricted to Independent Living residents. Residents residing in skilled care are not allowed access to the pool area.Monitoring observations and interviews were conducted on 3/21/26 through 3/23/26 on all shifts. The Admin, and ED, verified the in-service training and competencies that had been conducted to validate the staff understanding of the information presented to them. Interviews with CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, Health Info. Spl, RN A, RN B, RN C, Front Desk, LVN A, LVN B, all verified they received in-services training on door monitoring walking rounds around the pool and dog park with a checklist, checking emergency doorways fire doors and the alarm, missing and/or elopement residents skills checklists. Employees had to reenact a situation where management would identify a resident who has eloped and time to see if that resident could be located and what the protocol would be, in service training and including the abuse and neglect each staff member interview in this area were asked to identify three types of abuse in this area and most indicated physical verbal and financial; all employees identified the administrator as the abuse coordinator. All employees were asked about the in-service training regarding the unfamiliar person protocol. Each employee interviewed stated they all understood. They stated that if there is an unfamiliar person in the facility, you are required to ask questions to see if he or she is a resident and if there is a possibility that the unfamiliar person is a resident, then you must telephone the charge nurses on the units and request that they report to the area to identify the person and also, look in the protocol binder on each floor. The protocol binders on each floor have each residents face sheet to identify who the resident is and what floor the resident resides.On 3/23/26 at 10:00 am, observation and test were completed on the 2nd Floor with the emergency door. The emergency door was opened and closed quickly as to silence the door alarm. At 10:01am RN C and CNA G responded to the stairwell.On 3/23/26 at 4:41 pm telephone interview with MD - who stated that upon the admission of Resident 1 the facility was not advised that Resident 1 was an elopement risk. MD stated the local hospital did not advise the facility nor did they put it into the resident's discharge summary. She stated that the resident was not at the facility long maybe 36 hours so there was not a long history to measure with resident. She stated that this is a rehab facility and not a memory care facility and if they had known that Resident #1 had some cognitive deficiencies and was an elopement risk there's a high possibility she would not have been admitted to this facility. Since this incident, protocols have been updated, staff have been in-serviced, security have been in-serviced, there are checks and balances in the facility just in case there is a situation that may possibly occur in the future.On 3/21/26 at 8:15pm, the Administrator was notified that the IJ was removed; however, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the residents choices 1 of 5 residents (Resident #1) reviewed for quality of care. - The facility failed to ensure Resident #1 received orders for crushed medications as required after a speech therapy evaluation diagnosed him with dysphagia (difficulty swallowing) on 09/03/25 until 10/30/25.- The facility failed to ensure Resident #1 had orders to crush medications before administering crushed medications. This failure could result in resident's not receiving the care necessary, choking, and death. Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's undated care plan revealed, focus: Parkinson's; intervention: allow sufficient time for speech/communication, diet as ordered, encourage daily exercise, mobility as tolerated. Focus: diagnosis of HTN, retention of urine, Parkinson's disease, type two diabetes mellitus without complication, cancer of large intestine textured modified diet with thin liquids. Interventions: Monitor meal intake with each meal, Monitor weights as ordered. There was no care area for dysphagia or crushed medications. Record review of Speech Therapy: SLP Evaluation & Plan Treatment dated 09/03/25 revealed, diagnoses: Dysphagia, oropharyngeal phase ( the middle part of the throat, located behind the mouth and above the voice box). Dysphagia Medical WorkupPhysician's Signature = The signs/symptoms documented in Dysphagia Medical Work up have been identified through a dysphagia evaluation and I am in agreement with these findings. Precautions / contraindications: Swallow precautions in place, Puree diet and Fall risk. Dry Swallow = Impaired; Overall Abilities Swallowing Abilities = Mild/4. Pills/Meds = Mild; Clinical S/S Dysphagia: Crushed meds. Dysphagia Medical Workup Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase. Definite risk for: Aspiration (accidental inhalation of foreign substances, such as food, liquids, or air into the lungs), Choking and Wet or gurgly voice quality after swallowing liquids. Analysis- Behaviors Impacting Safety: Inattention to bolus (ball of chewed food) and Unsafe intake amounts w/decreased self-correction. Record review of Resident #1's admission Quarterly MDS 09/06/25 revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, independence with eating and substantial/maximal assistance for most functional abilities. Swallowing/Nutritional Status:; nutritional approaches: a mechanically altered diet. There was no diagnosis of dysphagia. Record review of Resident #1's Order Summary Report dated 10/30/25 revealed, no active orders to crush Resident #1's Medications. All previous orders to crush appropriate medications/open capsule if not contraindicated were discontinued. An observation on 10/30/25 at 12:23 PM revealed, Resident #1 lying in bed reading a newspaper. He said he received crushed medications because of difficulty swallowing but he didn't always have his medications crushed. Resident #1 said he had not had any episodes of choking, or aspiration. In an interview on 10/30/25 at 02:02 PM, the Administrator said medications should be crushed pursuant to a physician's order. She said crushed medications were normally administered to residents with swallowing issues or due to a resident's preference for crushed medications. The Administrator said failure to have orders for crushed medications could place residents at risk for negative/unintentional consequences and crushing medications without orders was against regulations. In an interview on 10/31/25 at 10:22 AM, the Interim DON said she was not aware of Resident #1 having swallowing issues but failure to have orders to crush medications for those with dysphagia, who required it, could place residents at risk of aspiration and choking. In an interview on 10/31/25 at 10:41 AM, RN B said Resident #1 received medications crushed due to prevent choking or aspiration. She said Resident #1 loved to take his medications with applesauce, and medications require an order to crush medications and failure to receive an order prior to administering could place residents at risk of adverse reactions while failure to have orders to crush medications for resident's with dysphagia could result in aspiration and choking. In an interview on 10/31/25 at 10:58 AM, LVN A said Resident #1 received his medication crushed, but she didn't know the reason why. She said prior to crushing medications there had to be an order in place, and failure to have orders for those who required their medications crushed could place them at risk of choking or aspiration. LVN A said since she worked with Resident #1 and she had observed no issues with choking or discomfort. In an interview on 10/31/25 at 11:03 AM, RN C said she did not crush medications for administration to Resident #1 because he did not have orders for crushed medications. She said an order was required prior to crushing medications and failure to have orders for crushed medications could result in aspiration and choking. RN C did not report any aspiration or choking with Resident #1. In an interview on 10/31/25 at 11:22 AM, LVN said Resident #1 had a modified diet due to chewing and swallowing problems and he had an order to crush all medications when he arrived, so it must have fallen off his orders. She said prior to crushing medications, there should be an order in place. She said failure to have orders for crushed meds for residents with swallowing disorders could place them at risk for aspiration and choking. In an interview on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. Record review of the facility's policy titled General Dose Preparation and Medication Administration revised 11/15/24 revealed, 2.7 Facility staff should crush oral medications only in accordance with pharmacy guidelines as set forth in Resource: Oral Dosage Forms that Should Not Be Crushed and/or facility policy. 2.7.1 Exceptions to Should Not Crush medications may occur when physician/prescriber orders are documented in the medical record including a statement explaining why crushing the medication will not adversely affect the resident.

Based on interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #2) whose records were reviewed for resident identifiable records. - LVN A failed to document accurately when she documented a change of Resident #2's water used for her oxygen concentrator on 10/26/25 when she did not complete it. This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings include Record review of Resident #2's Face Sheet dated 10/30/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: respiratory failure with hypoxia (low oxygen) and Hypercapnia (fast breathing), pneumonia (lung infection), COPD (group of breathing disorders that result in difficult breathing), and heart failure. Record review of Resident #2's admission MDS dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, and receipt of oxygen while a resident at the facility. Record review of resident #2's undated care plan revealed, focus- has oxygen therapy r/t CHF; interventions: oxygen settings: the resident has o2 via nasal prongs/mask at (2) L/min prn. Record review of Resident #2's Order Summary Report dated 10/30/25 revealed,- 10/03/25 Respiratory Orders: Oxygen Tubing Change every night shift every Sun for Oxygen Tubing Change- 10/03/25 Respiratory Orders: Oxygen-with Humidifier Record review of Resident #2's October 2025 TAR revealed,- LVN A signed that she changed Resident #2's oxygen tubing on Sunday 10/26/25. Record review of Resident #2's Oxygen readings from 10/03/25 to 10/29/25 revealed, no readings under 95%. An observation on 10/30/25 at 10:17 AM revealed, Resident #2 lying in bed receiving oxygen at 2 L/min via Nasal Canula. The water bottle connected to the oxygen concentrator was empty and with a date of 10/20/25. Resident #2 said she had no problems breathing or dry/irritated/bleeding nostrils. In an interview on 10/30/25 at 10:20 AM, RN A said nursing staff are expected to check a resident's oxygen level frequently, at least per shift, and document it in their MAR. She said the water on the concentrator serves to humidify the air being administered to prevent those receiving oxygen from experiencing dry nostrils that could lead to bleeding. RN A said when nurses signed off on O2 monitoring they are to inspect the volume of oxygen being delivered, the placement of the tubing and the presence of water. She said she did not notice Resident #2 was out of water, and the nurse scheduled for the Sunday evening shift was responsible for changing the water. RN A said the water for the humidifier is changed along with the tubing and both activities are documented under the order to change the tubing. In an interview on 10/31/25 at 10:22 AM, the Interim DON said O2 water and tubing should be changed every 7 days for infection control and to prevent contamination of the tubing and water She said failure to change the water and tubing could place residents at risk of infection and failure to humidify oxygen could result in drying of the nose, cracked and bleeding nostrils which result in discomfort. The Interim DON said when a nurse signs off on the MAR for changing the tubing they are also indicating that the water was changed and when they sign off every shift they are signing off on checking that the humidifier has water, the tubing is in good shape, and oxygen being received is as ordered. The Interim DON said failure to document accurately could place residents at risk of inaccurate documentation, missed services/treatment and care opportunities. Record review of the facility policy Routine Clinical Documentation revised 01/2018 revealed, Policy Overview: After admission, all services routinely provided to the resident will be documented in the resident's medical record, regardless of payor source. C. Clinical Nursing Documentation: 1. Daily: Medication administration record as indicated; Treatment administration record as indicated. The policy did not address accuracy of documentation. Record review of the facility policy Oxygen Management Policy revised 09/25 revealed, Policy Overview: This policy provides guidance for the safe storage and use of oxygen. B. Procedure 2. Oxygen Administration a. Verify that there is a physician's order for this procedure. Review the healthcare provider's orders or community protocol for oxygen administration. b. Review the resident's care plan to evaluate for any special needs of the resident. 3. Oxygen Use: b. The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. k. When humidifiers are used, they should be changed per the manufacturer's recommendation. Humidifiers should be checked periodically and changed as needed.

Based on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 8 resident (Resident #1) reviewed for accuracy of assessments. - The facility failed to accurately document Resident #1's dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS. This failure could place residents at risk of inaccurate assessments, which could compromise their plan of care . Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnoses which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's admission Quarterly MDS 09/06/25 revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, independence with eating and substantial/maximal assistance for most functional abilities. Swallowing/Nutritional Status: none of the; nutritional approaches: a mechanically altered diet. There was no diagnosis of dysphagia. Record review of Resident #1's undated care plan revealed, focus: Parkinson's; intervention: allow sufficient time for speech/communication, diet as ordered, encourage daily exercise, mobility as tolerated. Focus: diagnosis of HTN, retention of urine, Parkinson's disease, type two diabetes mellitus without complication, cancer of large intestine textured modified diet with thin liquids. Interventions: Monitor meal intake with each meal, Monitor weights as ordered. There was no care area for dysphagia or crushed medications. Record review of Resident #1's Order Summary Report dated 10/30/25 revealed, no active orders to crush Resident #1's Medications. Record review of Speech Therapy: SLP Evaluation & Plan Treatment dated 09/03/25 revealed, diagnoses: Dysphagia, oropharyngeal phase ( the middle part of the throat, located behind the mouth and above the voice box). Dysphagia Medical WorkupPhysician's Signature = The signs/symptoms documented in Dysphagia Medical Work up have been identified through a dysphagia evaluation and I am in agreement with these findings. Precautions / contraindications: Swallow precautions in place, Puree diet and Fall risk. Dry Swallow = Impaired; Overall Abilities Swallowing Abilities = Mild/4. Pills/Meds = Mild; Clinical S/S Dysphagia: Crushed meds. Dysphagia Medical Workup Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase. Definite risk for: Aspiration (accidental inhalation of foreign substances, such as food, liquids, or air into the lungs), Choking and Wet or gurgly voice quality after swallowing liquids. Analysis- Behaviors Impacting Safety: Inattention to bolus (ball of chewed food) and Unsafe intake amounts w/decreased self-correction. An observation on 10/30/25 at 12:23 PM revealed, Resident #1 lying in bed reading a newspaper. He said he received crushed medications because of difficulty swallowing but he didn't always have his medications crushed. Resident #1 said he had not had any episodes of choking, or aspiration. In an interview on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions, so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow, so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis was retrieved from hospital paperwork, doctors visits, and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from the diagnosis, the resident interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart she said, the resident had a diagnosis of dysphagia noted in his ST notes on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS, and there should be an associated focus area in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Certifying Accuracy of Resident Assessments with no revision date revealed, Policy Statement: Any person completing a portion of the Minimum Data Set/MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Policy Interpretation and Implementation: 1. Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. 4. The resident assessment coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the resident assessment coordinator, who is a registered nurse. There was no reference to the accuracy of assessments.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment describing services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Residents #1) reviewed for comprehensive care plans. - The facility failed to develop a care plan for Resident #1's diagnosis of dysphagia (difficulty swallowing) that required a modified diet and crushed medications in his diagnosis and MDS This failure could place residents at risk of not having their individual, medical, functional, and psychosocial needs identified and cause a physical, mental or psychosocial decline in health. Findings include: Record review of Resident #1's Face Sheet dated 10/30/25 revealed, a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis which included: kidney failure, difficulty walking, dementia, Parkinson's Disease (a brain disorder that affects movement, balance and coordination), stroke (interrupted blood flow to the brain that causes brain death) and history of stomach cancer. There was no documented diagnosis of dysphagia. Record review of Resident #1's admission Quarterly MDS 09/06/25 revealed, moderately impaired cognition as indicated by a BIMS score of 12 out of 15, independence with eating and substantial/maximal assistance for most functional abilities. Swallowing/Nutritional Status: nutritional approaches: a mechanically altered diet. There was no diagnosis of dysphagia. Record review of Resident #1's undated care plan revealed, focus: Parkinson's; intervention: allow sufficient time for speech/communication, diet as ordered, encourage daily exercise, mobility as tolerated. Focus: diagnosis of HTN, retention of urine, Parkinson's disease, type two diabetes mellitus without complication, cancer of large intestine textured modified diet with thin liquids. Interventions: Monitor meal intake with each meal, Monitor weights as ordered. There was no care area for dysphagia or crushed medications. Record review of Resident #1's Order Summary Report dated 10/30/25 revealed, no active orders to crush Resident #1's Medications. All previous orders to crush appropriate medications/open capsule if not contraindicated were discontinued. Record review of Speech Therapy: SLP Evaluation & Plan Treatment dated 09/03/25 revealed, diagnoses: Dysphagia, oropharyngeal phase ( the middle part of the throat, located behind the mouth and above the voice box). Dysphagia Medical WorkupPhysician's Signature = The signs/symptoms documented in Dysphagia Medical Work up have been identified through a dysphagia evaluation and I am in agreement with these findings. Precautions / contraindications: Swallow precautions in place, Puree diet and Fall risk. Dry Swallow = Impaired; Overall Abilities Swallowing Abilities = Mild/4. Pills/Meds = Mild; Clinical S/S Dysphagia: Crushed meds. Dysphagia Medical Workup Swallowing Disorder Phase: The above named patient is currently under my care and found to have a swallowing disorder involving the Oral Phase and Pharyngeal Phase. Definite risk for: Aspiration (accidental inhalation of foreign substances, such as food, liquids, or air into the lungs), Choking and Wet or gurgly voice quality after swallowing liquids. Analysis- Behaviors Impacting Safety: Inattention to bolus (ball of chewed food) and Unsafe intake amounts w/decreased self-correction. An observation on 10/30/25 at 12:23 PM revealed, Resident #1 lying in bed reading a newspaper. He said he received crushed medications because of difficulty swallowing but he didn't always have his medications crushed. Resident #1 said he had not had any episodes of choking, or aspiration. In an interview on 10/31/25 at 12:23 PM, the Speech Pathologist said she provided services to Resident #1 for his dysphagia. She said the resident was on swallowing precautions so he was ordered a soft diet ( dietary medication that consists of easily chewed and swallowed food), on thin liquids, alternating bites, crushed medications and sat upright when eating. She said when evaluated, Resident #1 held food and liquids in his mouth making it difficult to swallow so he required a double swallow. The Speech Pathologist said Resident #1 should not be taking medications whole because there was a risk of swallowing. She said his dysphagia and need for crushed meds should be included in his care plan, and it was nursing's responsibility to ensure he had a plan of care for his dysphagia. In an interview on 10/31/25 at 12:29 PM, the NP said Resident #1 was one of her patients and he had difficulty swallowing. She said she could not say if Resident #1 required crushed medications, that an order for crushed medications would be determined following an evaluation by ST and then she would approve the order. The NP said she would not answer hypotheticals regarding potential risks to residents with dysphagia receiving whole medications. In an interview on 10/31/25 at 12:56 PM, the MDS Nurse said she was responsible for adding a resident's diagnosis to their medical record and she completed MDS(s) and care plans along with her colleague that was currently on leave. She said a resident's diagnosis is retrieved from hospital paperwork, doctor's visits and therapy assessments. The MDS Nurse said the information from a resident's MDS was developed from the diagnosis, the resident interview and other clinical documentation. She said Resident #1 had a modified diet and was managed by speech therapy so dysphagia should be included in his diagnosis. After she reviewed Resident #1's chart she said, on the resident had a diagnosis of dysphagia noted in his ST notes on 09/03/25 so it should have been a diagnosis on his face sheet, documented in his MDS and there should be an associated focus area in his care plan. The MDS Nurse said on 10/30/25, when the surveyor entered the facility, Resident #1's face sheet, MDS, and Care Plan were inaccurate because they did not address his dysphagia and need for crushed medications. She said his diagnosis and care plan was updated on 10/30/25 after the surveyor alerted the facility to the discrepancy. The MDS Nurse said incorrect assessments/diagnosis could place residents at risk for not receiving proper care because the MDS and diagnosis did not indicate the resident's swallowing problems which resulted in the resident not having an accurate care plan. She said failure to care plan diagnosis like dysphagia could place residents at risk for choking and death. An attempt was meant on 10/31/25 at 02:29 PM to contact the Interim DON in regards to accuracy of diagnosis, assessments and care plans via telephone. A voicemail and text message were sent, the Interim DON did not return the surveyors call prior to exit. Record review of the facility's policy titled Comprehensive Care Plan revised November 2017 revealed, Policy Overview: A comprehensive, person-centered Care Plan will be developed for each resident that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental and psychosocial needs that have been identified through a comprehensive assessment. Policy Detail: A. A person centered, comprehensive care plan will be developed and implemented in accordance with the following: 1. The Comprehensive Care Plan will describe treatments and services to assist the resident to attain or maintain the highest level of physical, mental and psychosocial wellbeing. 2. The comprehensive care plan is based on a comprehensive assessment which includes, but is not limited to, the MDS, Care Area Assessments, clinical assessments and data collection forms, Therapy Evaluations, psychosocial and cognitive evaluations, physician assessments/consults. 4. Each resident's comprehensive care plan will describe: a. Resident goals for care and desired outcomes b. Identified resident issues, conditions, risk factors and safety issues c. The resident's unique characteristics and strengths.

Based on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preference for 1 of 5 residents (Resident #2) reviewed for respiratory care. - The facility failed to ensure to change the water in Resident #1's oxygen concentrator (a machine that supplies concentrated oxygen) on 10/26/25 which resulted in the bottle being empty while the concentrator was in use and administering oxygen to the resident on 10/30/25. This failure could place residents at risk for dryness, irritation, nosebleeds, sore throats, thickened secretions, discomfort, and infection due to the dry oxygen. Findings include: Record review of Resident #2's Face Sheet dated 10/30/25 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: respiratory failure with hypoxia (low oxygen) and Hypercapnia (fast breathing), pneumonia (lung infection), COPD (group of breathing disorders that result in difficult breathing), and heart failure. Record review of Resident #2's admission MDS assessment dated [DATE] revealed, intact cognition as indicated by a BIMS score of 14 out of 15, and receipt of oxygen while a resident at the facility. Record review of resident #2's undated care plan revealed, focus- has oxygen therapy r/t CHF; interventions: oxygen settings: the resident has o2 via nasal prongs/mask at 2 L/min PRN. Record review of Resident #2's Order Summary Report dated 10/30/25 revealed,- 10/03/25 Respiratory Orders: Oxygen at 2 liters per nasal cannula every shift for Hypoxia- 10/03/25 Respiratory Orders: Oxygen Tubing Change every night shift every Sun for Oxygen Tubing Change- 10/03/25 Respiratory Orders: Oxygen-with Humidifier Record review of Resident #2's October 2025 TAR revealed,- LVN A signed that she changed Resident #2's oxygen tubing on Sunday 10/26/25.- RN B signed that she checked on Resident #2's Respiratory orders on the night shift on 10/29/25.- LVN C signed that she checked on Resident #2's Respiratory orders on the evening shift on 10/29/25. Record review of Resident #2's Progress Notes from 10/03/25 to 10/30/25 revealed, no documented nasal irritation, or bleeding. An observation and interview on 10/30/25 at 10:17 AM revealed, Resident #2 lying in bed receiving oxygen at 2 L/min via Nasal Canula. The water bottle connected to the oxygen concentrator was empty and with a date of 10/20/25. Resident #2 said she had no problems breathing or dry/irritated/bleeding nostrils. In an interview on 10/30/25 at 10:20 AM, RN A said nursing staff were expected to check a resident's oxygen level frequently, at least per shift, and document it in their MAR. She said the water on the concentrator served to humidify the air being administered to prevent those receiving oxygen from experiencing dry nostrils that could lead to bleeding. RN A said when nurses signed off on O2 monitoring, they were to inspect the volume of oxygen being delivered, the placement of the tubing and the presence of water. She said she did not notice Resident #2 was out of water, and the nurse scheduled for the Sunday evening shift was responsible for changing the water. RN A said the water for the humidifier was changed along with the tubing and both activities are documented under the order to change the tubing. In and interview on 10/30/25 at 02:54 PM, LVN A said she worked with Resident #2 on Sunday 10/26/25. She said when a resident received oxygen, staff are expected to monitor the settings on the concentrator and the resident's o2 levels on each shift. She said the water is used to humidifier the oxygen delivered because oxygen can try out the nostrils. LVN A said if a resident's oxygen was not humidifier due to the bottle being empty they would be at increased risk for dry nostrils and bleeding. She said she changed the water weekly on the 11 PM- 7 AM shift along with the tubing for infection control/prevent contamination of the water and this task was documented under the change tubing task in the TAR. LVN A said she worked with Resident #2 over the weekend, and she thought she changed the oxygen with the tubing. She said if she documented it, she should have done it because she could not remember any issues with Resident #2's oxygen on the weekend of 10/26/25. She said failure to documents accurately, placed residents at risk of missed services or care and adverse reactions. In an interview on 10/31/25 at 10:22 AM, the Interim DON said O2 water and tubing should be changed every 7 days for infection control and to prevent contamination of the tubing and water She said failure to change the water and tubing could place residents at risk of infection and failure to humidify oxygen could result in drying of the nose, cracked and bleeding nostrils which result in discomfort. The Interim DON said when a nurse signed off on the MAR for changing the tubing they were also indicating that the water was changed, and when they signed off every shift they were signing off on checking that the humidifier had water, the tubing was in good shape, and oxygen being received was as ordered. The Interim DON said failure to document accurately could place residents at risk of inaccurate documentation, missed services/treatment, and care opportunities. In an interview on 10/31/25 at 10:41 AM, RN B said when she worked with Resident #2 overnight on 10/29/25, and the water for the humidifier was bubbling, so there was water in the bottle. She said Resident #2 did not have any issues with her nostrils or have any complaints of dry nose, cracking or bleeding. RN B said she missed the date on the water because she checked to ensure it was bubbling and the water and tubing were supposed to be changed every Sunday in the evening to prevent contamination and infection. In an interview on 10/31/25 at 11:47 AM, LVN C said when she worked with Resident #2 on the evening shift on 10/29/25. She said she monitored the resident's oxygen level, the settings on the tank and monitored the water. LVN C said the water for the humidifier was low, but it was still bubbling and functioning. She said the water was changed every Sunday but if it emptied sooner, nurses could change it. LVN C said she didn't notice the date on the water was 10/20/25, and Resident #2 reported no respiratory issues on her shift. Record review of the facility's policy Oxygen Management Policy revised September 2025 revealed, Policy Overview: This policy provides guidance for the safe storage and use of oxygen. B. Procedure 2. Oxygen Administration a. Verify that there is a physician's order for this procedure. Review the healthcare provider's orders or community protocol for oxygen administration. b. Review the resident's care plan to evaluate for any special needs of the resident. 3. Oxygen Use: b. The nurse should monitor oxygen administration and record the resident's response to oxygen therapy in the medical record. k. When humidifiers are used, they should be changed per the manufacturer's recommendation. Humidifiers should be checked periodically and changed as needed.

Based on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 2 of 2 floors (1st floor and 2nd floor) reviewed for required postings. - On 10/30/25, the facility failed to ensure the Daily Associate Posting included the name of the facility and was displayed in a prominent place readily accessible to residents, staff and visitors by hanging it on the corner wall of the nursing station located on one end of the hall on the 1st and 2nd floor.- On 10/31/25, the facility failed to ensure the Daily Associate Posting on the 1st and 2nd floor included the resident census. This failure could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings include: An observation on 10/30/25 at 10:29 AM revealed the facility's Daily Associate Posting hanging on a clip board on the corner of a wall across from the 1st floor nursing station. The name of the facility was not on the posting and the location of the posting was at the end of the left side of a T shaped hallway. An observation on 10/30/25 at 10:48 AM revealed, the facility Daily Associate Posting hanging on a clip board on the corner of a wall across from the 2nd floor nursing station. The name of the facility was not on the posting and the location of the posting was at the end of the left side of a T shaped hallway. In an interview on 10/30/25 at 10:55 AM, the Staffing Coordinator said she was responsible for the staffing schedule and the Daily Associate Posting. She said she did not know the CMS requirements for the Daily Associate Posting and she didn't receive any training prior to gaining the responsibility for creating the posting. She said she didn't know what was supposed to be included and she just completed the template. The Staffing Coordinator said the Daily Associate Postings were located on a clipboard on a corner wall across from the 1st and 2nd floor nursing stations and their purpose was to inform all visitors what staff were in the building. She said the location of the posting across from the nursing station at one end of the T-shaped hall was not in a place where everyone could see it, and it would only be seen by individuals who visited the nursing station located on one side of the hallway. In an interview on 10/30/25 at 02:44 PM, the Administrator said the Staffing Coordinator was responsible for the Daily Associate Posting. She said the posting must be displayed in a location visible to everyone, and it must be posted everyday and include the facility's name, date, census and the staffing for each shift. She said the location of the posting was only visible to anyone that comes in that direction and it was not visible to everyone who entered the facility. The Administrator said the Staffing Coordinator did not receive any training prior to completing the Daily Associate Posting and failure to have the posting in a location visible to all would result in visitors not knowing what the facility staffing was. An observation on 10/30/25 at 01:33 PM revealed the facility's Daily Associate Posting hanging on a clip board in the open sitting area before the hallway leading to 1st floor resident rooms. The facility name was on the posting but the resident census was not on the posting. An observation on 10/30/25 at 01:34 PM revealed, the facility Daily Associate Posting hanging on a clip board in the open sitting area before the hallway leading to 2nd floor resident rooms. The facility name was on the posting but the resident census was not on the posting. In an interview on 10/31/25 at 01:36 PM, the Staffing Coordinator said when she made the schedule on 10/31/25, she forgot to include the census because she forgot to update her premade schedules. She said failure to include the resident census would leave people unaware of the number of residents in the building. Record review of a blank Daily Associate Posting implemented 11/28/17 hanging on the clipboard on the 2nd floor revealed, the document was a photocopy and there was no location name on the form. Record review a SAMPLE Daily Associate Posting implemented 11/28/17, the original document read Location Name at the top left corner of the form. Record review of the facility's policy titled Benefits Improvement Protection ACT (BIPA) Daily Associate Posting revised 10/20/25 revealed, Policy Overview: A daily schedule of licensed and unlicensed nursing associates who are responsible for resident care, should be posted in a prominent location, allowing associates, residents and visitors to view this information. The schedule should include the number and categories of nursing associates scheduled for each shift as well as the total number of hours worked. Staffing is determined by resident population adhering to state and federal regulations. Clinical Services should complete the Clinical Services Sign-in Sheet on every shift. Policy Detail: 1. On a daily basis, a designated associate should post the community-specific number of direct caregivers scheduled for each shift in a 24-hour period by categories of nursing associates employed by the community, as well as the total number of hours worked by both licensed and unlicensed associates directly responsible for resident care. Direct care is interpreted as registered nurses, licensed practical/vocational nurses, and Certified Nursing Assistants (CNAs). 3. The designated associate member should post the community's name, current date and resident census, as well as the community specific shift schedule for a 24-hour period. The community decides when the 24-hour (daily) period for posting information begins and ends. 4. Data must be displayed in a clear and readable format and be posted in a prominent place readily accessible to residents and visitors.

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 3 residents (Resident #1) reviewed for pharmaceutical services.LVN C failed to remain in the room and monitor Resident #1's Family Member A administer medications to Resident #1. This failure could place residents at risk of not receiving the therapy needed. Findings included:Record review of Resident #1's admission MDS Assessment, dated 11 /14/25, reflected the resident was a [AGE] year-old male, who admitted to the facility on [DATE]. The resident's diagnoses included spinal stenosis, lumbar region without neurogenic claudication (degenerative condition characterized by the narrowing of the spinal canal in the lower back), hypertension (high blood pressure), diabetes mellitus (disease that occurs when blood sugar are too high), and anxiety disorder (feeling of fear, and uneasiness). Resident #1's BIMS score was not completed. Record review of Resident #1's Care Plan, dated 11/14/25, did not address medication administration. Observation on 11/18/25 at 9:22 AM, LVN C entered Resident #1's room, LVN C had a clear cup with pills inside. Resident #1's family member took the cup with pills and began to give Resident #1 pills 1 by 1. LVN C was observed checking Resident #1's blood pressure then blood sugars, once done checking LVN C was observed leaving the room before ensuring Resident #1 took all his medications. Resident #1's family member was observed still administering two pills after LVN C left the room. LVN C was observed to return to her med cart that was located at end of the hall by the nurse's station. Interview on 11/18/25 at 9:27 AM, Resident #1 was observed sitting in his chair. Resident #1 stated he was doing well, Resident #1's Family Member A stated she had just finished giving resident last 2 pills. Resident #1's Family Member A stated Resident #1 does better and will take all his medications when she gives them to the resident. Resident #1's Family Member A stated she ensures he takes them all. Interview on 11/18/25 at 10:46 AM, LVN C revealed she was the nurse assigned to Resident #1. She stated she provided Resident #1's morning medication. LVN C stated Resident #1's family member gives the pills to Resident #1 because he swallows them better when family member gives them to him. LVN C stated she left the room and returned to the room to ensure that all his medications were taken. She stated she had good communication with Resident #1's Family Member and the Family Member ensured her Resident #1 took all his medications. LVN C stated it was the metformin pill that was still in the cup when she left the room. She stated she should had stayed in the room to ensure all medications was taken. She stated the potential risk of not staying in the room to ensure all medications was given would be someone else taking the medications. Interview on 11/18/25 at 3:47 PM, Unit Manager D revealed nurses should follow the five rights of medication administration which were right patient, right drug, right dose, right route, and right time. She stated nurses should stay with the residents until all medications had been administered. She stated she was made aware of the situation with LVN C leaving the room. She stated it was a failure if the nurse left without ensuring all medications was administered. Unit Manager D stated the potential risk would be resident choking.Interview on 11/18/25 at 4:45 PM, the DON revealed all nurses should follow the five rights of medication administration. She stated all nurses should stay in the room to ensure all medications had been administered. She stated LVN C failed to ensure that the resident swallowed all his medications before leaving the room. The DON stated the potential risk would be anything could happen to the medication if left unattended. Record review of the facility's Medication Administration policy, revised May 2025, reflected the following: A. FOR ORAL MEDICATION ADMINISTRATION: . 7. Observe the client taking the medication.

Based on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for expired foods. The facility failed dispose of perishable foods after use in the walk-in fridge. This failure could place residents at risk for consuming hazardous expired food and developing foodborne illnesses who received food from the kitchen. Findings Included: Observation on 06/17/2025 at 10:48 AM revealed the following: *a bottle of Bay Leaves with use by date of 05/31/2025. * a package of Pork with use by date of 06/14/2025; *a package of Beef with use by date of 06/15/2025; *a package of Beef Tips with use by date of 06/10/2025; *a package of Brisket with use by date of 06/03/2025; and *a container of Chocolate Fudge Icing with use by date of 04/27/2025. An interview on 06/19/2025 at 11:22 AM with [NAME] A who revealed they have been trained on kitchen processes including discarding expired foods. [NAME] A stated that if there are expired foods in the facility it should be thrown away. [NAME] A stated there should not be any expired foods in the facility. [NAME] A stated a negative impact this could have on residents was the potential for illness. An interview on 06/19/2025 at 11:45AM with DM who revealed he has received training on topics including kitchen storage. DM stated the process for checking expired foods was done two times a day, once in the morning and once in the evening. DM stated this was monitored by the DM and shift manager on duty. DM stated if there are expired foods it should be thrown away. DM stated a negative impact this could have on residents was the potential for illness. An interview was conducted on 06/19/2025 at 12:00PM with DSD who revealed he has received training in topics including kitchen storage as well as labeling and dating system. DSD stated the process for checking for expired food was completed in the AM and PM. DSD stated if foods are expired, they should be thrown away. DSD stated a negative impact this could have on residents could be detrimental illness. An interview was conducted on 06/19/2025 at 12:05PM with EC who revealed he has received training on topics including kitchen storage and labeling. EC stated the expectation for expired foods is to throw it out immediately. EC stated himself and the sous chef monitor the expiration of food items. EC stated a negative impact this could have on residents was it could make them sick. An interview was conducted on 06/19/2025 at 1:15PM with ADM who revealed the dietary services manager provides the training to kitchen staff. ADM stated the policy for dated foods was to throw them away when they are expired. ADM stated the DSD was in charge of the functionality in the kitchen. ADM stated that the kitchen should be checking for expired foods two times a day, once in the AM and in the PM. ADM stated this could cause a negative impact on residents if they consumed the expired foods. Record Review of facility policy titled Labeling Safety and Sanitization dated November 2024 stated, 1.Upon receipt from vendors, all non-perishable food items must be labeled with the received date (month and year) before putting in dry storage. This should be done even if the food item has a use by or sell by date marked by the manufacturer. 2.All prepared items must have a label with the name of item, date and time prepared, by whom, and discard/use by date. Discard/use by dates should be no more than 3 days for leftovers/hazardous foods and 7 days for all other prepared food. Supervisors are responsible for ensuring food items in pantry, refrigerators, and freezers are not past use by or expiration dates.

Based on interview, and record review, the facility failed to ensure 1 of 6 residents (Resident #1) reviewed for wound care received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new ulcers from developing, in that: - The facility failed to identify a healed area to Resident #1's sacrum which included a scab and pink skin when Resident #1 admitted to the facility on [DATE]. Appropriate interventions were not implemented for Resident #1 and the area developed into a pressure ulcer within approximately 12 days of admission and eventually developed into a Stage IV pressure ulcer. - CNA B stated she did not reposition the resident frequently enough while working with Resident #1 upon her first few days admission. This failure placed residents with low skin integrity at risk for skin breakdown or failure of wounds to heal. Findings included: Resident #1 Record review of Resident #1's face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses of fracture of head and neck of left femur, and Alzheimer's disease. Record review of Resident #1's admission MDS , dated 08/15/2024 reflected no BIMS score as resident was assessed to be never/rarely understood. Resident #1's MDS also reflected her need for touching assistance/supervision for eating and substantial/maximal assistance for bed mobility. The resident was also assessed to be at risk of pressure injuries and was noted to have a surgical wound. Record review of Resident #1's care plan, dated 11/18/2024, reflected resident, .has a Stage IV pressure ulcer to sacrum w/ potential for pressure ulcer development [related to] impaired mobility ., with interventions including dietary supplementation, low air loss mattress, assisting with turning and repositioning as needed (starting 08/08/2024), and monitoring effectiveness of wound treatment. Record review of Resident #1's hospital discharge summary, dated 08/08/2024, reflected the resident had a pressure injury to right buttocks starting 08/04/2024 and an incision wound to left hip starting on 08/05/2024. Record review of Resident #1's progress notes, dated 08/08/2024 at 6:39PM revealed LVN C wrote an admission note documenting , .Resident non-verbal and unable to participate in medical history . Needs assistance with eating and drinking . Resident observed with surgical site to left hip . There were no other skin concerns disclosed in her notes. Record review of Resident #1's TAR, dated August 2024, reflected the resident was ordered remedy clinical silicone barrier cream twice a day for preventative treatment with each incontinence episode starting 08/13/2024. The TAR also reflected resident was later ordered clinical zinc paste every shift for skin care preventative with each incontinence episode starting 08/15/2024. Record review of Resident #1's TAR, dated August 2024, reflected the resident was ordered : - wound care to left inner buttock starting on 08/18/2024 and ending on 08/19/2024. - wound care to sacrum starting on 08/20/2024 and ending 09/14/2024. Record review of Resident #1's wound doctor's assessment, dated 08/16/2024, revealed the resident had: - a non-pressure wound on sacrum full thickness, measuring 1.3 X 4.1 X 0.1cm = 5.33cm squared surface area with a duration of greater than three days, and etiology being trauma/injury from a transfer. The resident was recommended zinc ointment once daily, cleansing wound at time of dressing change, and off-loading wound. Record review of Resident #1's wound doctor's assessment, dated 08/22/2024, revealed the resident had: - a non-pressure wound on sacrum full thickness, measuring 2.2 X 4.1 X 0.1cm = 9.02cm squared surface area. Resident was ordered a dressing treatment plan and was recommended to have wound cleansed at time of dressing change, off-load wound, turn side to side in bed ever 1-2 hours, a low air loss mattress and vitamin C supplementation. Observations of Resident #1 on 11/21/2024 at 8:25AM, revealed the resident was in bed being fed by a CNA. Resident #1 was lying on a low air loss mattress. In a phone interview with LVN C on 11/22/2024 at 2:44PM, she stated all nurses do their own wound care because there is no dedicated wound case nurse. She stated Resident #1's skin was not open on admission, but appeared to only have what looked like a healed, pink-colored scab on her buttocks that was not open. She stated she could not recall documenting the pink skin but after some time of being there she was told it had reopened. She stated in the beginning of Resident #1's stay, the resident had a regular mattress and she was not asked for help by her aides to reposition the resident but the aides repositioned the resident themselves. She stated immobility and poor nutrition can both contribute to skin breakdown and turning every two hours could help prevent further skin breakdown. She stated that she believed there was not a risk in not reporting scabs found on the resident because the skin was technically open. She stated she was not told by any nursing aides that Resident #1's skin was opening. In a phone interview with CNA D on 11/25/2024 at 9:08AM, she stated when Resident #1 first came to the facility, her bottom was clear. She said she eventually noticed skin breakdown on the resident's bottom and notified her nurse. She stated initially the resident, who unable to turn herself, did not have an air mattress and she did not help reposition her outside of the times she provided the resident with incontinent care because the resident was getting in her wheelchair and going to therapy. She stated she started repositioning her more often using pillows and wedges only after the skin breakdown started. She stated the resident likely developed the skin breakdown because she was not being turned as much. She also stated she knew that residents with bed immobility were supposed to be repositioned every two hours once they came in, but she did not know where to reference what care, such as repositioning, should be provided to certain residents. She stated she felt that she could only discover the level of care residents needed only after interacting with the residents because she is not told that information upfront by the nurses. In an interview with the DON on 12/03/2024 at 9:42AM, she stated LVN C should have noted the pink scab she found on Resident #1 upon admission considering that finding could indicate vulnerability of the patient's skin. This could have possibly led to more preventative measures being put in place at an earlier time for Resident #1 to help prevent further skin breakdown. In a phone interview with the DON on 11/25/2024 at 7:40PM, she stated for Resident #1, they had interventions in place from the start to prevent skin breakdown, including application of barrier cream by nurse aides and zinc ointment by nurses after incontinent care. She stated the goal was to use frequent incontinent care, barrier ointment and repositioning as interventions to maintain skin integrity and the air mattress was introduced later as an additional intervention due to the ineffectiveness of the initial interventions. She stated nurse aides have been inserviced and audited on their knowledge to refer to the Kardex for resident ADLs such as frequent repositioning which is also listed in the care plan. She stated she believed aides are providing changing in a timely manner to their residents but did not believe repositioning was being done every two hours exactly. She believed Resident #1's issues with hydration, nutrition and immobility following fracture likely contributed towards her skin breakdown. In an interview phone interview with the Wound Physician on 11/26/2024 at 1:36PM, she stated the history came out that Resident #1 did have a pre-existing wound before and it was communicated in hospital's documentation. She stated they saw documentation on hospital documents saying that she had a wound before. She stated she is not sure if the nurse who initially did the skin assessment captured it. She stated she did not what to say whether Resident #1's sacral wound was avoidable or unavoidable because of the resident's issues with nutrition and overall she has had good progress so far. She stated since the wound was identified and treated, the resident has done well. She said a couple of weeks there was a stall related to the nutrition intervention, while talking with the family about placing a G-tube, but the resident had improved her nutrition status overtime. In terms of all the components being optimized she would say they optimized everything. She stated if there was a wound present before in the same location, there would always be a risk of the wound reopening, but the resident was already on an air mattress during her first evaluation of her. She stated she typically recommended air mattresses for residents with a Stage III or higher, and they look at immobility as a factor. She said if the staff were changing the position every 2 hours, there would be no reason for an air mattress. If the resident is declining and cannot reposition themselves, that is when they need the air mattress. Record review of the facility's policy and procedure on, dated March 2009, reflected, Charge nurse should: 1> Complete physical observation, documenting findings within the admission data collection form. If a wound is present on admission the Charge Nurse should initiate and describe the wound on the Weekly Wound Data Collection Sheet . 4. Initiate treatment intervention. 5. Initiate plan of care . Update plan of care with each intervention. The Certified Nursing Assistant (CNA) should: a. Complete documentation of new skin concerns as identified in Point of Care and notify the nurse as indicated . c. Provide skin care during routine care. D. Apply moisturizing creams, barrier products per the plan of care and scope of practice .

Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 1 resident (Resident #1) reviewed for infection. -The facility failed to ensure RN B performed hand hygiene during wound care for Resident #1. This failure could lead to the spread of infection to residents. Finding included: Record review of the admission sheet (undated) for Resident #1 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included Fracture of left femur, history of falling, presence of left artificial hip joint, hypertension (a condition in which the force of the blood against the artery walls is too high). Record review of Resident #1's Entry MDS, dated [DATE], revealed there was no section for BIMS score, functional status, urinary incontinence, and bowel incontinence . Record review of Resident #1's care plan, initiated 08/08/2024 revealed the following: Care Plan Description: Potential for and actual impairment to skin integrity related to impaired mobility, blister to upper right buttock and pressure injury to left buttock. Date Initiated: 11/18/24. Care Plan Goal: The resident will have no worsening of skin alteration through review date. Intervention; Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to MD. Record review of Resident #1's physician order dated 11/22/24 revealed an order to cleanse sacrum with normal saline, pat dry with gauze, use alginate rope to pack wound, collagen powder and cover with Opti-foam dressing. Observation on 11/22/24 at 08:38 am, revealed RN B provided Resident #1 with wound care. RN B was assisted by Unit Manager LVN P. RN B gathered the supplies at the treatment cart in the hallway before bringing them into Resident #1's room. Supplies included 1 bottle normal saline, 4 packages of 4x4 gauze, 1 package Maxorb II alginate, 1 package Opti-foam, 1 tongue depressor and three cups. Closed curtain for privacy and assisted resident on to her left side. LVN P held the resident on her left side, unfastened the resident's brief. RN B removed the resident's brief and dated sacral area wound dressing and placed in the garbage can at bedside. Continued observation revealed an open area of approximately 2-3 centimeters in diameter. RN B applied/cleaned with damp 4x4's the skin around wound, applied other 4x4's and applied/cleaned inside the wound, the applied/dried inner and outer wound area. Without washing/sanitizing hands or changing gloves, she placed collagen powder around and into the wound, then handled and applied alginate rope into wound with tongue depressor, placed Opti-foam over wound without washing/sanitizing hands or changing gloves. RN B completed wound care with the same soiled gloves on. In an interview on 11/22/2024 at 11:07 am, RN B stated washing/sanitizing hands was important to protect resident from infection. RN B reported she should have washed/sanitized her hands, placed clean gloves on after removing dirty dressing and prior to providing wound care with new wound dressing. RN B stated she doesn't know why she didn't remember to wash/sanitize her hands after removing dirty dressing/brief and before providing wound care treatment. Reports wound care training and infection training were performed with in the last month. In an interview on 11/22/2024 at 11:36 am, LVN P, she stated washing/sanitizing hands was important to protect resident from infection. LVN P reported RN B should have washed/sanitized her hands after removing dirty brief and sacral dressing prior to providing wound care with new dressing. Reports wound care training and infection training was performed with in the last month. In an interview on 11/22/2024 at 11:50 am, the DON stated it is important to wash/sanitize hands, place gloves on, obtain supplies, clean tabletop, provide protective barrier. Wash/sanitize hands, place on gloves, remove old dressing, wash/sanitize hands place gloves on, clean wound, wash/sanitize hands, place gloves on, provide treatment to wound, cover with dressing. The DON reported washing/sanitizing hands is important to protect resident from infection, she reported RN B should have washed/sanitized her hands prior to providing wound care with new wound dressing and thinks RN B may have been nervous while being observed. The DON reports wound care training and infection training was performed with in the last month. The DON said the expectation was to maintain infection control throughout the process. She said staff received in-service on infection control once or twice a month. She said nurses was provided training and competency check offs annually and as needed if noted concerns. The DON said she did do another competency check off and in-service with RN B. Record review of facility's Infection Prevention and Control Program dated (Revised July 2018) read in part: .Policy Statement: An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Record review of facility's Wound Care Competency revised 02/2020 for RN B performed on 11/22/2024 read in part: . 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 6. Put on gloves. 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with wound cleanser or normal saline. 12. Perform hand hygiene. 13. Apply treatments as indicated. Record review of facility's Procedure: Wound Care . 5. Pull glove over dressing and discard into appropriate receptacle. Perform hand hygiene. 6. Put on gloves. 11. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with wound cleanser or normal saline. 12. Perform hand hygiene. 13. Apply treatments as indicated. Record review of facility's Handwashing/Hand Hygiene policy dated (October 2015 Last revised 01/2021) read in part: .Policy Overview: This community considers hand hygiene the primary means to prevent the spread of infections. Policy Detail: B. All associates shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other associates, residents, and visitors. C. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for associates use to encourage compliance with hand hygiene policies. G. CDC recommends using Alcohol Based Hand Sanitizer with 60-95% alcohol in healthcare settings. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water during routine resident care. 7. Before handling clean or soiled dressings, gauze pads, etc.; 8. Before moving from a contaminated body site to a clean body site during resident care;10. After contact with blood or bodily fluids;11. After handling used dressings, contaminated equipment, etc.

Based on interview and record review, the facility failed to ensure for 1 of 12 residents (Resident #4) reviewed for resident assessments was assessed using the quarterly review instrument not less frequently than once every 3 months, in that: - Resident #4's EHR showed her quarterly MDS assessment was due for completion by 4/10/2024 but was not done by time of record review on 04/24/2024. This failure placed residents at risk of not receiving adequate care. Findings included: Record review of Resident #4's face sheet, dated, revealed a [AGE] year-old female who was admitted into the facility on [DATE] and was diagnosed with vascular dementia, Parkinson's disease and protein calorie malnutrition. Record review of Resident #4's last comprehensive MDS, revealed it was dated 01/09/2024. Record review of Resident #4's EHR revealed the resident's quarterly ARD was due by 4/10/2024. In an interview with the MDS Nurse on 04/24/24 at 1:41PM, she stated assessment for admission assessments, quarterly assessments and discharge assessments are all completed within 14 days and the DON then has 7 days to sign off on the assessment and transmit the MDS to CMS . She stated follows the guidance as stated in the RAI manual. She stated she was not aware that she had missed Resident #4's quarterly MDS. She stated she forgot to complete Resident #4's MDS and, as of 04/24/2024, her MDS should have been completed since it was already beyond the 3-month period since her last MDS was completed. In an interview with the DON, on 04/24/24 at 2:52PM, she stated she signed MDS assessments when they were due, but she was not involved in auditing the MDS Nurse's work. She stated she expected the MDS to be completed on time and knew that it could affect billing and updates in resident care plans. Record review of the RAI Manual, dated 2019, revealed a quarterly MDS must be completed within 14 calendar days after ARD and a discharge MDS must be completed within 14 days after discharge date .

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7 % based on 2 errors out of 28 opportunities, which involved 2 of 6 residents (Resident #8, Resident #42) reviewed for medication errors. 1-LVN A failed to administer medications as physician ordered to Resident #8 as by not administering Esomeprazole Magnesium delayed release 40mg on 04/23/2024. The original order for Esomeprazole 40mg twice a day was dated 3/13/2024.The order status was on hold because the medication was out of stock on 04/23/2024. 2-LVN B failed to administer medications as ordered to Resident #42 as by administering Vitamin B12 with Folate instead of the physician order for Vitamin B12 without folate on 4/23/2024. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications. Findings included: 1.Record review of Resident #8's Diagnoses sheet dated 04/23/2024 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: GERD (gastro-esophageal reflux) and personal history of digestive system disease. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 has an alteration in gastro-intestinal status r/t cholangitis (inflammation of the bile duct). Interventions included: give medications as ordered. Focus - Resident had GERD. Interventions included: give medications as ordered. Record review of Resident #8's April 2024 MAR (medication administration records) revealed, on 04/23/2024 the 9:00 AM dose of Esomeprazole Magnesium delayed release 40mg was not given but was put on hold. Record review of Resident #8's nursing progress note dated 4/23/2024 at 9:06 AM, LVN A wrote that the Omnicell was checked for Esomeprazole 40mg, and the medication was not present. Contacted the pharmacy to check on status of order and that it was refilled. The NP was notified, no new orders and holding medication until medication arrives. Record review of Resident #8's Order Summary Report received from the DON dated 04/24/2024 at 11:37 AM revealed, Esomeprazole Magnesium oral capsule delayed release 40mg, give every morning and at bedtime, start date 03/13/2024. The order status was on hold. An observation and interview on 04/23/24 at 08:12 AM revealed, LVN A preparing medication for administration to Resident #8. LVN A administered all ordered 9:00 AM medications by 8:33 AM except for Esomeprazole. LVN A stated she would check the Omnicell for the Esomeprazole 40 mg and that it just may be out of stock. LVN A stated she did not know why it was not available. In an interview on 04/24/2024 at 9:19 AM, LVN A stated Resident #8 has a personal history of acid reflux and if she did not receive Esomeprazole as physician ordered then heart burn could begin. 2.Record review of Resident #42's Diagnoses sheet dated 04/04/2024 revealed an [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included a fracture to the right thigh bone, heart disease, and unstageable pressure ulcer to the sacrum. Record review of Resident #42's undated Care Plan revealed, focus- Resident had altered cardiovascular status. Interventions included administer medications as ordered. Focus - Resident had Unstageable pressure ulcer to sacrum. Interventions included: Vitamin C and multivitamins with minerals for wound healing. Further review did not include Vitamin B12 and Folic Acid. Record review of Resident #42's Order Summary Report dated 04/24/2024 revealed an order for Vitamin B12 1000 mcg, give 1 tablet daily for Vitamin insufficiency, order start date was 04/05/2024. Further review revealed an order for Folic acid 1mg, give daily for vitamin insufficiency, order start date 04/05/2024. Record review of Resident #42's April 2024 MAR dated 04/23/2024 at 10:59 AM, revealed LVN B documented she administered Vitamin B12 1000mcg on 04/23/2024 on arising (between 7:00 AM and 10:00 AM). An observation on 04/23/24 at 09:09 AM revealed, LVN B preparing medication for administration to Resident #42. LVN B administered 2 tablets of Vitamin B12 with folate 500 mcg and Folic acid 1 mg tablet. In an interview on 04/23/2024 at 11:30 AM, LVN B stated she gave Resident #42 Vitamin B12 from the bottle with the label Vitamin B12 with folate 500mcg because she did not have Vitamin B12 without folate in her cart. LVN B stated she was not aware that it contained folate (folic acid) and that the resident also received folic acid 1 mg tablet. When asked if she gave the correct medication as physician ordered she stated she would check to see if there was stock Vitamin B12 bottles and would call the NP to ask for the order to be changed. In an interview on 04/24/2024 at 10:50 AM, the DON stated the nurses were responsible for reordering the Esomeprazole through the online electronic health record system, before they run out for sure at least 3 days prior. The DON stated the night shift nurses were responsible for auditing the medication rooms and medication carts but not individual medications. The DON stated she would have to trust the nurses to be aware of when medications run low. Record review of the facility policy titled General dose Preparation and Medication Administration, dated 12/01/2007 read in part: .4.1 Facility staff should: .Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route .

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of 1 of 6 residents (Resident #42) reviewed for pharmaceutical services. -The facility failed to administer the medication Esomeprazole (used to treat stomach acid related conditions) to Resident #8 on 04/21/2024, 04/22/2024 and 04/23/2024 as physician ordered. This failure could place residents receiving medication at risk of inadequate therapeutic outcomes and discomfort. Findings included: Record review of Resident #8's Diagnosis sheet dated 04/23/2024 revealed, an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included: GERD (gastro-esophageal reflux) and personal history of digestive system disease. Record review of Resident #8's annual MDS dated [DATE] revealed she had a BIMS score of 9 out of 10. She required substantial assistance to partial assistance with all ADLs. Record review of Resident #8's undated Care Plan revealed, focus- Resident #8 has an alteration in gastro-intestinal status r/t cholangitis (inflammation of the bile duct). Interventions included: give medications as ordered. Focus - Resident had GERD. Interventions included: give medications as ordered. Record review of Resident #8's undated order details for Esomeprazole Magnesium delayed release 40 mg, one capsule every morning and at bedtime every day, revealed the order date 3/13/2024. Record review of Resident #8's April 2024 MAR (medication administration records) revealed, on 04/23/2024 the 9:00 AM dose of Esomeprazole Magnesium delayed release 40mg was not given and was put on hold. Resident received Esomeprazole as ordered from 04/01/2024 to 9:00 AM on 4/21/2024. Record review of Resident #8's MD progress note dated 4/14/2024 revealed the date of service was 4/12/2024 and the resident denied acid reflux and heartburn. Record review of Resident #8's nursing progress note dated 04/21/2024 at 9:46 PM, LVN C wrote the Esomeprazole Magnesium 40 mg was pending. Record review of Resident #8's nursing progress note dated 04/22/2024 at 8:37 AM, LVN A wrote the Esomeprazole Magnesium 40 mg was pending. Record review of Resident #8's April 2024 MAR (medication administration records) revealed, on 04/23/2024 the 9:00 AM dose of Esomeprazole Magnesium delayed release 40mg was not given but was put on hold. Record review of Resident #8's nursing progress note dated 4/23/2024 at 9:06 AM, written by LVN A revealed that the Omnicell was checked for Esomeprazole 40mg, and the medication was not present. LVN A contacted the pharmacy to check on status of the order and that it was refilled. The NP was notified, no new orders and holding medication until medication arrives. Record review of Resident #8's nursing progress note dated 04/23/24 at 2:32 PM, written by LVN A, revealed the Esomeprazole was refilled in Fort Worth and would be coming from there. LVN A cancelled the request to fill the medication at a Houston location and should be received on the evening delivery run. An observation and interview on 04/23/24 at 08:12 AM revealed, LVN A preparing medication for administration to Resident #8. LVN A administered all ordered 9:00 AM medications by 8:33 AM except for Esomeprazole. LVN A stated she would check the Omnicell for the Esomeprazole 40 mg and that it just may be out of stock. LVN A stated she did not know why it was not available. In an interview on 04/24/2024 at 9:12 AM, Resident #8 stated she had stomach issues for a very long time and had taken medication for it, that always helped her stomach feel better. She stated in the last few days she had been having indigestion. In an interview on 04/24/2024 at 9:19 AM, LVN A stated Resident #8 had a personal history of acid reflux and if she did not receive Esomeprazole, as physician ordered, then heart burn could begin. LVN A stated typically once a medication was down 3-4 doses, she would reorder. LVN A stated she would place a reorder online, or call pharmacy directly, or fax the label. LVN A stated all nurses were responsible to reorder. LVN A stated she would also reorder a medication if it popped up on the PCC during her shift. LVN A stated once a medication was not available, she would notify the physician. LVN A stated when she notified the NP on 04/23/24, the NP did not reorder an alternative medication for the Esomeprazole, the order was to hold. In an interview on 04/24/2024 at 9:40 AM, RN D stated if she would reorder medications when only 3 to 4 days left because she would not want a resident to suffer from not receiving their medications. RN D stated the nurses were responsible to reorder every shift and if a follow up was needed at the end of her shift she would report to the oncoming nurse. In an interview on 04/24/2024 at 10:50 AM, the DON stated the nurses were responsible to reorder medications at least 3 to 4 days before running out. The DON stated she expected the nurses to call the physician right away and ask if the medications can be held and restarted once received from pharmacy then check in with the pharmacy right away. She stated if the medication was OTC, then it can be picked up at local pharmacy. The DON stated the night shift nurses were responsible for auditing the medication rooms and medication carts but not individual medications. The DON stated she would have to trust the nurses to be aware of when medications run low. She stated she reminds the nurses they must reorder when only 3 days left on medications. The DON stated Resident #8's Esomeprazole should have been reordered on 4/19/2024 or 4/20/2024. In an interview on 04/24/2024 at 2:07 PM, the DON stated she checked Resident #8's records and confirmed that the resident received a dose of Esomeprazole on 04/21/2024 at 11:45 AM, the evening dose was missed and the next dose she received was on 04/24/204 in the morning. The DON states she did not know why the medication was not available the evening of 04/21/2024. She stated the medication could have been picked up at the local pharmacy but d/t the higher dose of 40 mg, it needed to be ordered. Record review of the facility policy titled: Reordering, Changing and Discontinuing Orders, revised on 01/01/2013, read in part: .This policy 4.5 sets forth procedures with respect to Facility's communication of any medication reorders, changes or discontinuations to Pharmacy .2.1 Reorders can be written and submitted on the refill order form .2.2 Verbal refill order can be submitted verbally .2.3 Reorders can be faxed to Pharmacy .2.4 Electronic orders: Authorized Facility staff may use . Further review revealed the policy did not include when to place reorders when medications run low.

Based on interview and record review the facility failed immediately consult with the resident's physician when there is a significant change in the resident's physical status for 1 (Resident #1) of 5 residents reviewed physician notification. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later 2/20/2024. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on [DATE] at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. This failure could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life threatening infections, hospitalization , and worsening pressure ulcers. Findings included: Record Review of Resident #1's Face Sheet undated revealed an [AGE] year old female who was admitted to facility on 2/8/2024 with diagnoses of Other fracture of left femur (Bone that runs from hip to knee), subsequent encounter for closed fracture with routine healing (Unopen fracture), Encounter for other orthopedic after care (At facility for rehabilitation), Extended Spectrum Beta Lactamase (ESBL) resistance (Antibiotic resistant urinary infection), Urinary Tract Infection where urine is excreted), Morbid Severe Obesity due to excess calories, Type 2 Diabetes Mellites with Hyperglycemia (High blood sugar). Record Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 9 indicating the resident was moderately cognately impaired, Resident #1 required extensive assistance with ADLs. Section I revealed fractures and other multiple traumas, urinary tract infection last 30 days, Swallowing Disorder . Risk of pressure injuries .yes, Unhealed pressure ulcers/Injuries yes .Unhealed pressure ulcers/injuries Yes .stage 1 .0 .Stage 2 .0, Stage 3 .0. Stage 4 .0 (No pressure injuries at admission) Unstageable deep tissue injury .1 .MASD (Moisture Associated Skin Damage). Record review of Resident #1's Care Plan dated 2/9/2024 read in part .Resident #1 has potential/actual impairment to skin integrity . Interventions: Assist with turning and reposition as needed. Reduce friction and shearing with use of lift or transfer sheets 2/8/2024 .Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc to MD. 2/8/2024 . Record Review of Resident #1's Comprehensive Nursing notes dated 2/16/2024, 2/18/2024 and 2/19/2024 read no new or worsening skin conditions. Record review of Resident #1's orders dated 2/20/2024 read . Cleanse sacrococcygeal ulcer (Area above and center of buttocks) with NSS (normal saline), Pad Dry, apply calcium alginate (Fabric) and med honey (medication for healing) and cover with sacral dressing (area at top and center of buttocks) qd (daily). Record Review of Resident #1's BD Weekly Wound Data Collection Flow Sheet dated 2/20/2024 revealed wound 6.5x14.0 depth, unstageable. Record Review of Resident #1's Change of Condition dated 2/20/2024 read in part . Skin status evaluation .pressure ulcer injury .Sacrum .unstageable pressure wound. 3/2/2024 Family Member #1 removed Resident #1 from the skilled nursing facility and took her to the hospital due to the pressure wound on her sacrum. Record Review of Resident #1's hospital records dated 3/2/2024 to 3/11/2024 revealed Resident #1 was admitted to the hospital with diagnoses of Infected decubitus ulcer (Infection at buttocks), unspecified ulcer stage. 8.0 x 10.0 x Unstageable due to 80% adherent necrotic tissue. Resident underwent Incision and drainage of sacral wound on 3/5/2024, intraoperative cultures grew Protease mirabilis (Bacteria in Urine infections), ESBL E. coli MDR (Harder to treat with antibiotics) and Enterococcus faecalis Pan sensitive (Bacteria found in the intestine). Resident #1 was discharged with orders for IV Meropenem (Intravenous antibiotic) every 8 hours for 21 days. Interview 3/13/2023 at 10:30am the Assistant Director Clinical Services said if a nurse found a wound and the skin was broken the expectations were to clean it, put a dry dressing on it and contact the Nurse Practitioner or Doctor for the findings and get and order for wound care. If that was not done the wound could have possibly deteriorated even more. She said they wanted staff to put in nursing interventions and needed them to offload from the wound. She said looking back they saw there was no notification to the physician and no orders for wound care for 2 days. She said they did rounds with the wound care physician so when the wound was found, they put interventions in place, making sure the wound care physician was notified, made sure the proper treatments were in place and notified the family. Interview 3/13/2024 at 10:44am with Family Member #1 he said he had to take his Resident #1 out of the nursing facility himself as the facility transportation would not take him to the hospital of his choice and he wanted Resident #1 to go to a particular hospital for her wound. He said he had to initiate the transfer as the facility said Resident # 1 did not need to go to the hospital. He said Resident #1 was in the hospital for nine days for her infected bedsore and she had been discharged the previous day to another nursing facility. Interview on 3/13/2024 at 1:20pm with LVN A she said she worked on 2/18/2023 in the evening. She said the weekend supervisor told her Resident #1 had a wound on her sacrum. She said she thought the weekend supervisor was going to manage everything. She said she did not necessarily say she was going to manage everything, she said she thought they were going to handle the wound together. She said she guessed it was her fault the physician was not called about the wound even the CNAs were telling her they were reporting it to previous nurses the day before on 2/17/2024. They said there were bandages on the wound already and there were bandages in the room. She said the CNAs that told her they were from the weekend shifts. They said the bandage fit on the specific part for the sacrum. She said the CNAs had been putting the bandage on the wound and said they had been reporting it to previous nurses. She said the weekend supervisor looked at the wound. She said she thought the supervisor was going to call the doctor. She said she had not worked at the facility in 2 or 3 weeks. She said she talked to the DON and ADON about the wound and they asked how it looked at the time, they wanted to know if it looked black at that time. She said the wound was large. She said no one had previously reported a wound to the sacrum. No one had reported a wound on Saturday. She said she had been a nurse for one year, worked at the facility for one month, and was in-serviced on wound care in February 2024. Interview on 3/13/2024 at 2:00pm, CNA K said she remembered Resident #1. She said she came back from 5 days off and had her as a patient and when she was changing her, she saw she had redness and told her nurse. She said from then on, they started turning Resident #1 every 2 hours to get her off her bottom. She said this was on Wednesday February 21, 2024. She said when she saw the wound it was very large, very tender, obvious it had been there for a few days. She said the skin was broken. She said it was very vibrant colored, so she reported it to LVN B. She said she had been a CNAs for 10 months and worked at the facility for 5 months. She said prior to this happening she was in-serviced on wounds at a retirement home and was reminded at this facility. She said the facility had done an in-service . She said they had shown them how to add notes so they could have said they told the nurse about wounds and so the residents could have gotten treatment. Interview on 3/13/2024 at 2:50pm CNA L said she worked on Sunday 2/18/2024. She said she had only worked with Resident #1 a handful of times, and she was dead weight. She said when she got to Resident #1, she noticed a wound with no covering on her back side (2/16/2024). She said another CNA said she noticed it the day before on 2/17/2024, but she did not remember who it was. She said this had to have happened about a month ago if not more. She said the skin was broken off at the back and butt crack and she told the nurse but could not remember who on the morning shift. She said the wound looked pretty bad and looked like it would have stung. She said it was medium to large. She said they should have known about the wound if the CNA noticed it before her. She said it was a Sunday. She said she did not really know some of the nurses. She said she had worked at facility 7 months and been a CNA for 3 years. She said she was last in-serviced on skincare the prior weekend, and before that 3 months ago. Interview on 3/13/2024 at 3:55pm CNA M she said she was not at the facility at first but when she came back on 2/16/2024, she saw Resident #1 had a wound to her buttocks. She said she told the nurse it needed to be cleaned and it had an odor. She said the wound was open, large and had an odor. She said the skin was off the wound. She said she told the nurse LVN C about the wound, but she did not do anything about it because after that she got a call from the DON asking about the wound and when it started. An interview with LVN C could not be conducted as she was in the hospital. Record review of Resident #1's Braden Scale for predicting pressure ulcer risk dated 2/15/2024 read Resident #1 had slightly limited sensory perception, was bedfast, occasionally moist, made frequent though slight changes in body or extremity position independently, friction or shear was a potential problem, and the total score was above 16. (Mild risk for pressure ulcers). Interview on 3/14/2024 at 2:55pm with the Assistant Director Clinical Services she said they did investigations with the staff to figure the gaps on Resident #1's wound. She said she looked herself and the skin initially was intact. She said even the week prior the evening nurse showed on the 14th it was intact. She said it was Resident #1's positioning, nutrition, and incontinence, and it was a combination that caused the wound. She said she knew they were putting zinc on the wound. She said on Sunday 2/20/2024, the CNA had identified and informed the off going nurse on the 3 to 11shift of the wound and she looked at it and told RN S. She said LVN A told RN S Resident #1 had skin breakdown and could she look at it look at it let her know. She said RN S said she would help LVN A if she needed it. The Assistant Director Clinical Services stated according to the RN S she told the nurse to get the information and call the doctor. LVN A said she would call the doctor and get the order. The Assistant Director Clinical Services stated It was he said she said situation. She said she had not heard anything about February 16th and when she did her weekly assessment on the 14th it was ok and there was no breakdown on the sacral area. She said the reason the resident had a sacral wound was because she had not been repositioned. She said when residents get sacral wounds, they can become infected. Interview on 3/14/2024 at 2:55pm with the ADON she said she did not know a CNA had reported skin breakdown to LVN C on 2/16/2024. She said on 2/18/2024 LVN A and RN S told her it was the others responsibility to call the physician. She said LVN C told her RN S would call the physician for orders and RN S said LVN A would call the physician for orders. She said RN S should have called the physician for orders for wound care as she was the person who reported to the oncoming staff. On 3/13/2024 at 11:05am outreached RN S who had been terminated by the facility for not contacting the physician for wound care orders, and she refused the interview. Interview on 3/15/2024 at 8:30am with the ADON she said the failure with Resident #1's wound was a combination of timely identification of the wound and not getting timely treatment in place. She said Resident #1 was being treated for ESBL (Antibiotic Resistant bacteria) and E. coli (Intestinal bacteria) in urine. She said Resident #1 had a slight decrease in mobility and it was their job to have repositioned her, to have been timely in reporting the wound, and she said the reason Resident #1 developed the wound was because she was not repositioned enough. She said she had been a part of the QAPI (Quality Assurance and Performance Improvement) subcommittee, with KPI (report to look at metrics and pressure ulcers) were worked on this year, she said this issue was disheartening, she said they had identified wounds and they had multiple sessions with the nurses. She said she thought the failure was communication regarding Resident #1. She said they educated the staff so when they saw something to report it. She said staff were to report skin breakdown instead of someone assuming it had already been reported. She said Resident #1 did not really want to be turned and Resident #1 could have gotten the wound by not being turned, she said Resident #1 needed assistance with turning. She said what should have happened was as soon as anything was different with Resident #1's skin, they should have reported to the charge nurse starting at the stage 1. She said staff should have notified charge nurse, notified wound care physician, and gotten orders for wound care. Interview on 3/15/2024 at 6:46am CNA N said she worked the night shift last night. She said she had worked at the facility for [AGE] years and been a CNA for 20 plus years. She said she worked on the first floor. She said she saw Resident #1's wound. She said she saw her wound, but she was not assigned to her, but she did see it, she said she assisted with turning. She said when Resident #1 needed changing she would assist with changing her. She said Resident #1 would call and let us know when she was ready to be changed. She said Resident #1 was with it and she was coherent. She said she saw the bedsore and saw the wound as medium sized, she said they would have patches on it, they would clean it and put patches on it. She said she told the nurse about the wound, and they had so many since then she did not know the name of the nurse, she reported it to. She said she did not know if the ADON knew about the wound. She said she was sure she did, she said you can tell nurses about a wound but after that you do not know what happens. She said if a resident was not turned, they could have gotten a bedsore and it could have gotten larger. She said it could have gotten infected. She said she did not know how Resident #1 got the bedsore but had been shocked to hear about it and said she saw it when it was smaller. Interview on 3/15/2024 7:31am with LVN D she said she had worked at the facility for about 5 weeks. She said she had been a nurse for 2 years. She said she saw the wound on Resident #1's sacrum. She said the wound was unstageable when she saw it. She said it was red around the perimeter and black on the inside. She said she did not believe the CNA reported the wound. She said she believed there was a dressing on the wound on Friday 2/16/2024. She said she did not know it had not been reported to the physician as they each had a list of comprehensive nursing notes to write, and she had not documented on her. She said the CNA told her there was a wound and it was not dirty. She said she did not call the physician. She said they do skin checks on the 7 to 3 and 3 to 11 shifts so they would have called and received an order as she worked nights. She said she found a wound on Resident #1's inner thigh the following week and called the wound care physician and received an order for that. She said if a resident had a bedsore, they could get an infection and have pain. She said she did not know how long Resident #1's sacral wound had been there. Interview on 3/15/2024 at 7:33am with CNA O she said she had worked at the facility since October 2023, she said she would have been a CNA for a year in May 2024. She said she had seen the wound on Resident #1's sacrum and reported it to the nurse. She said she reported it to LVN D because the bandage was soiled, and she took it off so that LVN D could replace it. She said LVN D came in and replaced the bandage. She said she saw the wound after Valentines Day . She said she did not work on weekends, so it was on Thursday 2/15/2024, or Friday 2/16/2024. She said it was not the week of 2/23/24. She said if a resident was not turned, they could have gotten a bedsore, the bedsore could have gotten worse, and the resident could have gotten an infection. Record Review of facilities policy titled, Skin Observation and Wound Prevention Protocol dated 10/2022 read in part . Charge nurses should observe the condition of the resident's skin on admission and on a routine basis. Record Review of facilities policy titled, Change of Condition for Skilled Nursing Communities dated 8/2023 read in part .An associate should communicate information about a residents status change to appropriate licensed personnel upon observation .or observing a difference in the residents usual physical .the licensed nurse should .notify the HCP (Healthcare provider) of observations and relevant change of condition information .Implement treatment interventions, received orders and document HCP recommendations as indicated . Record Review of Facility In-Service dated 2/2/2024, 2/3/2024 and 2/7/2024 .Topic .Annual Charge Nurse Check-off Training read in part . Importance of pressure wound prevention .Doctors, On-call, Telehealth. Record Review of Facility In-Service dated 2/20/2024 .Topic . Offloading/Repositioning read in part .Repositioning patients throughout shift to offload bony prominences .offload areas at risk for breakdown . Record Review of Facility In-Service dated 2/21/2024 .Topic .Infection Control read in part . Signs and Symptoms of wound infection: Swelling, Redness, Slight odor, increased pain at wound site . Record Review of Facility In-Service dated 3/13/2024 .Topic .Reporting New or Progression of Wound read in part .CNA to report New or Worsening wounds too Charge nurse immediately .Document Change in Skin Condition in PCC using Stop-N-Watch Tool .Charge Nurse to report New or Worsening wounds to Physician/NP to receive wound care orders immediately .Charge Nurse should place call to DCS (Director Clinical Services) or ADCS (Associate Director Clinical Services) to inform of New or Worsening wound identified. An IJ was identified on 4/1/2024 and the facility administrator was notified at 7:00pm. The IJ template was provided to the facility on [DATE] at 4:14pm. On 4/3/2024 at 4:40pm the following Plan of Removal was accepted. Plan of Removal Brookdale Galleria - April 2, 2024 F580 Notifications of Changes Immediate Action: On 2/19/2024, an impromptu Quality Assurance Performance Improvement (QAPI) Meeting was completed with the Healthcare Administrator (HCA), Director of Clinical Services, Assistant Director of Clinical Services (ADCS), and Medical Director via the phone related to the Skin Management Process related to Resident # 1 skin documentation. The additional actions included re-education to Certified Nursing Assistance (C.N.As) and Licensed Nurses on repositioning and abuse neglect reporting. Re-education for Licensed Nurses on skin assessments, Skin observation protocol (which includes notification of healthcare provider), repositioning, and wound prevention. These Inservices were completed on 2/20 by the ADCS. On 2/20/2024, the ADCS and Attending Physician assessed the wound to Resident #1's sacrum and new orders received by the attending physician for medical honey and calcium alginate, supplements, and a low air loss mattress. On 2/22/2024 the Third Party Wound Doctor assessed the wound, orders were updated to include Santyl. The Third Party Wound Doctor discussed the skin management plan of care with the resident # 1 representative at bedside. On 2/22/24, the ADCS performed wound rounds on current residents with wounds. No new pressure concerns were noted. On 3/2/24, Resident # 1 discharged from the community. On 3/13/24, an Impromptu QAPI Meeting held with the HCA, ADCS, Regional Director of Clinical Services (RDCS), and the Medical Director via the phone related to the Skin Management Process. The additional actions included the ADCS or designee to extend the audits of 5 residents dressing to be completed weekly for 90 days, review residents that would benefit from a Low Air Loss Mattress, complete skin checks on current residents, and re-education to C.N.A's and Licensed Nurses to notify the DCS or ADCS on new pressure ulcers. The regional support nurse conducted an audit on 3/14 no additional findings relating to physician notification were noted. On 3/13-3/14/24, the ADCS and designee completed skin checks on current residents. No new pressure concerns were noted. On 3/14/24, a Registered Nurse (RN) performed a remote Skin Documentation Audit. The audit included the following items. The audit was documented on an audit form. o Weekly Skin Integrity Review form to verify every resident had either the weekly skin form or the section completed in the Nursing Admission Data Collection form, if newly admitted . o That every resident had a weekly skin integrity review activated schedule to be completed weekly in PCC. Form scheduled as needed in PCC. o Weekly Wound Data Collection form if completed, the date, and information in the form. o Third Party Wound Care MD notes in PCC Miscellaneous tab with notes on wounds (location, etc.) o Third Party Wound Care MD orders from their notes on wounds from bullet above. o Physician orders written in PCC for wounds or anything related to skin. o Care Plans related to wounds. Plan for Compliance: From 3/13/- 3/16/2024, the DCS or designee re-educated all Licensed Nurses on change of condition documentation which includes notifying physician and representative, skin documentation, obtaining orders for any wounds, reviewing and addressing clinical alerts on skin concerns from C.N.A's, notifying provider as indicated, professional standards of wound care, that the C.N.A can't apply a treatment, Braden Scale which includes preventative measures. Licensed nurses not available between 3/13/2024 to 3/16/2024 received re-education by the DCS or designee before their next scheduled shift and this will include new hires hired after 3/16/2024. Competency validated with a post test. From 4/1 -4/3 the DCS or designee re-educated nurse on physician notification of new skin issues, change of condition documentation, aides performing dressing changes, skin observation and wound prevention protocol. Licensed nurses not available between 4/1 to 4/3 will receive re-education by the DCS or designee before their next shift, this will include new hires hired after 4/3. Competency validated with a post test. Starting 3/14/24, the Licensed Nurses will initiate the wound data collection sheets on any new pressure ulcers. The RAI or designee will update resident care plans as needed as new pressure concerns arise. The Licensed Nurse will review the clinical alerts in the dashboard periodically through the shift to verify that any new skin concerns communicated by the C.N.A are addressed. The ADCS or designee overseeing will complete the weekly wound data collections for residents with new pressure ulcers until pressure ulcer is resolved or the resident is discharged . Order listing report, progress notes, weekly skin and wound documentation is reviewed during daily standup for any new or worsening pressure ulcers. From 3/13- 3/16/24, the ADCS or designee re-educated all C.N.A.s on communication of changes in skin integrity with the licensed nurse and DCS or ADCS, documentation of any new skin concerns in the electronic medical record every shift including the stop and watch, what to do if dressing falls off the resident's wound, moisture barriers, and turning and repositioning. The C.N.A may complete a Stop and Watch Alert that there is a Change in skin color or condition as indicated. These alerts display on the licensed nurse clinical alert dashboard in the electronic medical record. The C.N.A will also communicate verbally to the licensed nurse what they documented in the electronic medical record related to new skin concerns. The C.N.A. will contact the DCS, ADCS, or the Healthcare Administrator to report new skin issue for additional follow up. C.N.As not available between 3/13- 3/16/23 received re-education by the DCS or designee before their next scheduled shift and this will include new hires hired after 3/16/24. Competency validated with a post test. From 4/1 to 4/3 C.N.A. were re-educated on C.N.A. not performing dressing changes and are allowed to apply barrier cream, reporting changes in skins and wound prevention. Aides not available between 4/1 to 4/3 will receive re-education by the DCS or designee before their next shift, this will include new hires hired after 4/3. Competency validated with a post test. For 90 days, the DCS or designee will review clinical alerts in stand-up meeting five days a week, to determine if there is documentation of new skin concerns noted by a C.N.A. and verify that appropriate follow up and documentation was completed by a licensed nurse as indicated. The licensed nurses will review clinical alerts including the stop and watch periodically through their shifts daily, to assist with identification of new skin concerns documented by the C.N.A's. For 90 days, the ADCS or designee will audit the weekly skin integrity review for 5 residents a week to verify completion, validate accuracy with a head-to-toe skin check, confirm that appropriate skin care orders are in place as applicable, and notification of the Healthcare was completed as applicable if skin concerns identified. These audits will be documented on an audit form. For 90 days, the ADCS or designee will audit 5 residents' wound care orders a week to verify treatments were completed per physician orders. These audits will be documented on an audit form and reported in the next morning stand up meeting. For 90 days, the DCS or designee will review the audits monthly at the QAPI meeting. Compliance date: 4/3/2024 An IJ was identified on 4/1/2024 and the facility was notified at 7:00pm. The IJ template was provided to the facility on [DATE] at 4:14pm. The Immediate jeopardy was removed on 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. The surveyor monitoring was from 4/1/2024 to 4/4/2024. Immediate Jeapordy monitoring included: Record review on 3/13/2024 revealed a QAPI sign in sheets for 2/19/2024, 3/13/2024, 3/15/24, 3/20/2024, 3/27/2024 with sign in sheets in IJ book by Administrator, Infection preventionist/ADON, Medical Director (3/15/2024). Record review on 3/13/2024 of nurse's notes dated 2/20/2024 revealed the physician was notified immediately on 2/20/2024 at 1:51pm and orders implemented for wound care and wound care physician consulted. Record review on 3/13/2024 revealed staff in-services 2/20/2024 for Abuse and Neglect, the facility provided a copy of policy, Offloading and Repositioning, Skin observation and repositioning, 2/21/24 In-service included Hand Hygiene, Incontinent Care Cleansing, Signs and Symptoms of wound infection, Cleansing of Shared equipment, Handouts: Charge nurse responsibilities, Nursing Forms, Shift Report, Patient appointments and facility provided policy on infection control. Inservice 3/1/2024 Charge nurse responsibilities, 3/13/2024 Reporting new or progression of wound, 3/21/2024 Wound care paperwork, 3/25/2024 Infection Control. Facility provided policy. 3/25/24 Order Confirmation from Physician/NP. Record review on 3/13/2024 revealed wound care physician visit on 2/22/2024 Record review on 3/13/2024 of physician orders dated 2/23/2024 15:00 were updated to include Santyl Ointment as part of the residents wound care regimen. Record review on 3/13/2024 revealed staff were in-service 3/13/2024 Reporting New or Progression of Wound: CNAs t report new or worsening wounds to charge nurse immediately, Charge nurse to report new or worsening wounds to Physician/NP to receive wound care orders immediately, Charge nurse should place call to Director of Clinical Services or Assistant Director of Clinical Services to inform of New or worsening wound identified. Record review on 3/13/2024 revealed skin assessments performed on 2/21/2024 to 2/23/2024 and 3/13/2024. Record review 4/3/2024 revealed Woundcare Orders and Treatment audit for March 2024 Record review on 4/3/2024 revealed staff were in-serviced 4/2/2024 and 4/3/2024 for Physician notification for new skin issue, change of condition documentation, and CNAs and dressing changes. In-service included CNAs should never apply Zinc oxide to patients' body, change a wound dressing and if the dressing comes off during a shower or bath the CAN needed to notify the nurse to put a new dressing on the wound. The in-service was followed by a post test for CNA's. Record review on 4/3/2024 revealed staff were in-serviced 4/2/2024 for Skin observation/Wound prevention; facility provided policy. Record review on 4/3/2024 revealed audits on 4/2/2024 for residents admitted within the last 30 days for new pressure ulcers and notification to healthcare provider. Audit consisted of reviewing the weekly skin integrity forms, admission assessment and weekly wound data forms. Wound physician progress notes as indicated. No additional findings. Record review on 4/3/2024 revealed weekly skin integrity reviews for February 2024 and March 2024 revealed no new or worsening wounds. Observation of wound care on 4/3/2024 11:45am on Resident #6. Resident #6 noted to be on a low air loss mattress. Nurse washed hands, donned gloves, removed dressing, removed gloves, applied hand sanitizer .donned gloves, wiped wound from inside to outside with gauze impregnated with wound cleanser, removed gloves, hand sanitizer, donned gloves, patted are around wound for adhesion, removed gloves, hand sanitizer, applied calcium alginate and bordered dressing. Dated. Noted wound was healthy and healing, It appeared sacral wound had been larger at one time but now wound small, healthy red with granulation tissue. In an interview on 4/2/2024 at 12:47pm LVN E said she had been in-serviced a few times on wounds and wound care, she said she had been in-service the previous night on reporting new wounds to the physician, letting the unit manager and ADON know, calling the physician for orders and letting them know about changes in condition and weekly skin data. Interview on 4/2/2024 at 12:53pm CNA P said she was not supposed to change dressings on a resident, she said she was supposed to report missing or damaged dressings to the charge nurse or DON and document in the system who she told. Se said she would have reported skin breakdown to the charge nurse or DON, she said she had been in-service today, last week on wounds, change of condition, not to use zinc oxide and moisture barrier. Interview on 4/2/2024 1:00pm CNA Q said he had been in-service on wounds and wound care that morning. He said reporting wounds, new skin issues, not to change dressings, role as a CNAs, and when he saw redness or wounds to report and document in the system. He said he would have reported to the nurse and ADON. Interview on 4/2/2024 at 1:05pm CNA R said she had been in-service that day on what to do and what not to do with wounds and who to report them to. She said not to have changed dressings and not to apply Zinc Oxide. She said they were in serviced on reporting wounds to the nurse or DON and documenting in PCC system. Interview on 4/2/2024 at 1:30pm LVN F said he had been i [TRUNCATED]

Based on interview and record review the facility failed to ensure that a resident reviewed for pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for 1 (Resident #1) of 5 residents. 1. Facility staff identified sacral wound on Resident #1 on 2/16/2024 and facility staff failed to perform and document a wound assessment, notify the physician, and obtain wound care orders until 4 days later on 2/20/2024. Wound Care Physician assessed Resident #1 on 2/22/2024 and diagnosed Resident #1 with an unstageable (Due to Necroses) Sacrum Full Thickness pressure wound with a surface area of 129.72 cm. 2. Facility staff were performing dressing changes without a physician's order. An IJ was identified on 4/1/2024. The IJ template was provided to the facility on [DATE] at 4:14pm. The Immediate jeopardy was determined to have been removed 4/4/2024 due to the facilities implemented actions that corrected the non-compliance. This failure could affect residents with impaired skin integrity and residents at risk for impaired skin integrity of developing life threatening infections, hospitalization , and worsening pressure ulcers. Findings included: Record Review of Resident #1's Face Sheet undated revealed an [AGE] year old female who was admitted on [DATE] with diagnoses of Other fracture of left femur (Bone that runs from hip to knee), subsequent encounter for closed fracture with routine healing (Unopen fracture), Encounter for other orthopedic after care (At facility for rehabilitation), Extended Spectrum Beta Lactamase (ESBL) resistance (Antibiotic resistant urinary infection), Urinary Tract Infection where urine is excreted), Morbid Severe Obesity due to excess calories, Type 2 Diabetes Mellites with Hyperglycemia (High blood sugar). Record Review of Resident #1's MDS dated [DATE] revealed Resident #1 had a BIMS score of 9 indicating the resident was moderately cognately impaired, Resident #1 required extensive assistance with ADLs. Section I revealed fractures and other multiple trauma, urinary tract infection last 30 days, Swallowing Disorder, Risk of pressure injuries .yes, Unhealed pressure ulcers/Injuries yes .Unhealed pressure ulcers/injuries Yes .stage 1 .0 .Stage 2 .0, Stage 3 .0. Stage 4 .0 Unstageable deep tissue injury .1 .MASD (Moisture Associated Skin Damage). Record review of Resident #1's Care Plan dated 2/9/2024 read in part . Goal The resident will have no worsening of skin alteration . INTERVENTIONS: Monitor/document/report to MD changes in skin status: appearance, color, wound healing, signs/symptoms of infection, wound size and stage. Record Review of Resident #1's Comprehensive Nursing notes dated 2/16/2024, 2/18/2024 and 2/19/2024 read no new or worsening skin conditions. Record review of Resident #1's orders dated 2/20/2024 read . Cleanse sacrococcygeal ulcer (Area above and center of buttocks) with NSS (normal saline), Pad Dry, apply calcium alginate (Fabric) and med honey (medication for healing) and cover with sacral dressing (area at top and center of buttocks) qd (daily). Record review of Resident #1's orders for Februrary 2023 and March 2023 revealed Resident #1 was not placed on antibiotics before she went to the hospital. Record Review of Resident #1's Change of Condition dated 2/20/2024 read in part . Skin status evaluation .pressure ulcer injury .Sacrum .unstageable pressure wound. Record review of Resident #1's orders dated 2/21/2024 read .Pressure Redistribution Mattress-Low air loss. Record review of Resident #1's wound care notes dated 2/22/2024 read in part . Unstageable (due to necroses) sacrum full thickness .Etiology .pressure .Duration >6 days wound size 14.1x9.2x0.1cm . Surface area 129.72 .Thick adherent devitalized necrotic tissue 90%. 3/2/2024 Family Member #1 removed Resident #1 from the skilled nursing facility and took her to the hospital due to the pressure wound on her sacrum. Record Review of Resident #1's hospital records dated 3/2/2024 to 3/11/2024 revealed Resident #1 was admitted to the hospital with diagnoses of Infected decubitus ulcer (Infection at buttocks), unspecified ulcer stage. 8.0 x 10.0 x Unstageable due to 80% adherent necrotic tissue. Resident underwent Incision and drainage of sacral wound on 3/5/2024, intraoperative cultures grew Protease mirabilis (Bacteria in Urine infections), ESBL E. coli MDR (Harder to treat with antibiotics) and Enterococcus faecalis Pan sensitive (Bacteria found in the intestine). Resident #1 was discharged with orders for IV Meropenem (Intravenous antibiotic) every 8 hours for 21 days. Interview 3/13/2023 10:30am with the Assistant Director Clinical Services said if a nurse found a wound and the skin was broken the expectations were to clean it, put a dry dressing on it and contact the Nurse Practitioner or Doctor for the findings and get and order for wound care. If that was not done the wound could have possibly deteriorated even more. She said they wanted staff to put in nursing interventions and needed them to offload from the wound. She said looking back they saw there was no notification to the physician and no orders for wound care for 2 days. She said they did rounds with the wound care physician so when the wound was found, they put interventions in place, making sure the wound care physician was notified, made sure the proper treatments were in place and notified the family. Interview on 3/13/2024 at 1:20pm with LVN A she said she worked on 2/18/2023 in the evening. She said the weekend supervisor told her Resident #1 had a wound on her sacrum. She said she thought the weekend supervisor was going to manage everything. She said she did not necessarily say she was going to manage everything, she said she thought they were going to handle the wound together. She said she guessed it was her fault the physician was not called about the wound even the CNAs were telling her they were reporting it to previous nurses the day before on 2/17/2024. They said there were bandages on the wound already and there were bandages in the room. She said the CNAs that told her they were from the weekend shifts. They said the bandage fit on the specific part for the sacrum. She said the CNAs had been putting the bandage on the wound and said they had been reporting it to previous nurses. She said the weekend supervisor looked at the wound. She said she thought the supervisor was going to call the doctor. She said she had not worked at the facility in 2 or 3 weeks. She said she talked to the DON and ADON about the wound and they asked how it looked at the time, they wanted to know if it looked black at that time. She said the wound was large. She said no one had previously reported a wound to the sacrum. No one had reported a wound on Saturday. She said she had been a nurse for one year, worked at the facility for one month, and was in-serviced on wound care in February. Interview on 3/13/2024 at 2:00pm, CNA K said she remembered Resident #1. She said she came back from 5 days off and had her as a patient and when she was changing her, she saw she had redness and told her nurse. She said she could not remember the day when she first saw the redness on Resident #1. She said from then on, they started turning Resident #1 every 2 hours to get her off her bottom. She said this was on Wednesday February 21, 2024. She said when she saw the wound it was very large, very tender, obvious it had been there for a few days. She said the skin was broken. She said it was very vibrant colored, so she reported it to LVN B. She said she had been a CNAs for 10 months and worked at the facility for 5 months. She said prior to this happening she was in-serviced on wounds at a retirement home and was reminded at this facility. She said the facility had done an in-service. She said they had shown them how to add notes so they could have said they told the nurse about wounds and so the residents could have gotten treatment. Interview on 3/13/2024 at 2:50pm CNA L said she worked on Sunday 2/18/2024. She said she had only worked with Resident #1 a handful of times, and she was dead weight. She said when she got to Resident #1, she noticed a wound with no covering on her back side. She said another CNAs said she noticed it the day before on 2/17/2024, but she did not remember who it was. She said this had to have happened about a month ago if not more. She said the skin was broken off at the back and butt crack and she told the nurse but could not remember who on the morning shift. She said the wound looked pretty bad and looked like it would have stung. She said it was medium to large. She said they should have known about the wound if the CNA noticed it before her. She said it was a Sunday. She said she did not really know some of the nurses. She said she had worked at facility 7 months and been a CNA for 3 years. She said she was last in-serviced on skincare the prior weekend, and before that 3 months ago. Interview on 3/13/2024 at 3:55pm CNA M she said she wasn't at the facility at first but when she came back on February 16, 2024, she saw Resident #1 had a wound to her buttocks. She said she told the nurse it needed to be cleaned and it had an odor. She said the wound was open, large and had an odor. She said the skin was off the wound. She said she told the nurse LVN C about the wound, but she did not do anything about it because after that she got a call from the DON asking about the wound and when it started. Record review of Resident #1's Braden Scale for predicting pressure ulcer risk on 3/14/2023 read Resident #1 had slightly limited sensory perception, was bedfast, occasionally moist, made frequent though slight changes in body or extremity position independently, friction or shear was a potential problem, and the total score was above 16. (Mild risk for pressure ulcers). Interview on 3/14/2024 at 2:55pm with the Assistant Director Clinical Services she said they did investigations with the staff to figure the gaps on Resident #1's wound. She said she looked herself and the skin initially was intact. She said even the week prior the evening nurse showed on the 14th it was intact. She said it was Resident #1's positioning, nutrition, and incontinence, and it was a combination that caused the wound. She said she knew they were putting zinc on the wound. She said on Sunday February 20, 2024, the CNA had identified and informed the off going nurse 3 to 11 and she looked at it and told RN S. She said LVN A told RN S Resident #1 had skin breakdown and could she look at it look at it let her know. She said RN S said she would help LVN A if she needed it. According to the RN S she told the nurse to get the information and call the doctor. LVN A said she would call the doctor and get the order. It was he said she said. She said she had not heard anything about February 16th and when she did her weekly assessment on the 14th it was ok and there was no breakdown on the sacral area. She said the reason the resident had a sacral wound was because she had not been repositioned. She said when residents get sacral wounds, they can become infected. Unable to get an interview with RN S as she was terminated for not contacting the physician regarding the wound and obtaining orders for wound care. Interview on 3/14/2024 at 2:55pm with the ADON she said she did not know a CNA had reported skin breakdown to LVN C on 2/16/2024. She said on 2/18/2024 LVN A and RN S told her it was the others responsibility to call the physician. She said LVN C told her RN S would call the physician for orders and RN S said LVN A would call the physician for orders. She said RN S should have called the physician for orders for wound care as she was the person who reported to the oncoming staff. Interview on 3/15/2024 at 8:30am with the ADON she said the failure with Resident #1's wound was a combination of timely identification of the wound and not getting timely treatment in place. She said Resident #1 was being treated for ESBL (Antibiotic Resistant bacteria) and E. coli (Intestinal bacteria) in urine. She said Resident #1 had a slight decrease in mobility and it was their job to have repositioned her, to have been timely in reporting the wound, and she said the reason Resident #1 developed the wound was because she was not repositioned enough. She said she had been a part of the QAPI (Quality Assurance and Performance Improvement) subcommittee, with KPI (report to look at metrics and pressure ulcers) were worked on this year, she said this issue was disheartening, she said they had identified wounds and they had multiple sessions with the nurses. She said she thought the failure was communication regarding Resident #1. She said they educated the staff so when they saw something to report it. She said staff were to report skin breakdown instead of someone assuming it had already been reported. She said Resident #1 did not really want to be turned and Resident #1 could have gotten the wound by not being turned, she said Resident #1 needed assistance with turning. She said what should have happened was as soon as anything was different with Resident #1's skin, they should have reported to the charge nurse starting at the stage 1. She said staff should have notified charge nurse, notified wound care physician, and gotten orders for wound care. Interview on 3/15/2024 at 6:46am CNA N said she worked the night shift last night. She said she had worked at the facility for [AGE] years and been a CNA for 20 plus years. She said she worked on the first floor. She said she saw Resident #1's wound. She said she saw her wound, but she was not assigned to her, but she did see it, she said she assisted with turning. She said when Resident #1 needed changing she would assist with changing her. She said Resident #1 would call and let us know when she was ready to be changed. She said Resident #1 was with it and she was coherent. She said she saw the bedsore and saw the wound as medium sized, she said they would have patches on it, they would clean it and put patches on it. She said she told the nurse about the wound, and they had so many since then she did not know the name of the nurse, she reported it to. She said she did not know if the ADON knew about the wound. She said she was sure she did, she said you can tell nurses about a wound but after that you do not know what happens. She said if a resident was not turned, they could have gotten a bedsore and it could have gotten larger. She said it could have gotten infected. She said she did not know how Resident #1 got the bedsore but had been shocked to hear about it and said she saw it when it was smaller. Interview on 3/15/2024 7:31am with LVN D she said she had worked at the facility for about 5 weeks. She said she had been a nurse for 2 years. She said she saw the wound on Resident #1's sacrum. She said the wound was unstageable when she saw it. She said it was red around the perimeter and black on the inside. She said she did not believe the CNA reported the wound. She said it was Friday February 16, 2024. She said she believed there was a dressing on the wound on Friday February 16, 2024. She said she did not know it had not been reported to the physician as they each had a list of comprehensive nursing notes to write, and she had not documented on her. She said the CNA told her there was a wound and it was not dirty. She said she did not call the physician. She said they do skin checks on the 7 to 3 and 3 to 11 shifts so they would have called and received an order as she worked nights. She said she found a wound on Resident #1's inner thigh the following week and called the wound care physician and received an order for that. She said if a resident had a bedsore, they could get an infection and have pain. She said she did not know how long Resident #1's sacral wound had been there. Interview on 3/15/2024 at 7:33am with CNA O she said she had worked at the facility since October 2023, she said she would have been a CNA for a year in May 2024. She said she had seen the wound on Resident #1's sacrum and reported it to the nurse. She said she reported it to LVN D because the bandage was soiled, and she took it off so that LVN D could replace it. She said LVN D came in and replaced the bandage. She said she saw the wound after Valentines Day February 14, 2024, on Thursday or Friday. She said she did not work on weekends, so it was on Thursday February 15, 2024, or Friday February 16, 2024. She said it was not the week of February 23, 2024. She said if a resident was not turned, they could have gotten a bedsore, the bedsore could have gotten worse, and the resident could have gotten an infection. Record Review of facilities policy titled, Skin Observation and Wound Prevention Protocol dated 10/2022 read in part . Charge nurses should observe the condition of the resident's skin on admission and on a routine basis. Record Review of facilities policy titled, Change of Condition for Skilled Nursing Communities dated 8/2023 read in part .An associate should communicate information about a residents status change to appropriate licensed personnel upon observation .or observing a difference in the residents usual physical .the licensed nurse should .notify the HCP (Healthcare provider) of observations and relevant change of condition information .Implement treatment interventions, received orders and document HCP recommendations as indicated . Record Review of Facility In-Service dated 2/2/2024, 2/3/2024 and 2/7/2024 .Topic .Annual Charge Nurse Check-off Training read in part . Importance of pressure wound prevention .Doctors, On-call, Telehealth. Record Review of Facility In-Service dated 2/20/2024 .Topic . Offloading/Repositioning read in part .Repositioning patients throughout shift to offload bony prominences .offload areas at risk for breakdown . Record Review of Facility In-Service dated 2/21/2024 .Topic .Infection Control read in part . Signs and Symptoms of wound infection: Swelling, Redness, Slight odor, increased pain at wound site . Record Review of Facility In-Service dated 3/13/2024 .Topic .Reporting New or Progression of Wound read in part .CNA to report New or Worsening wounds too Charge nurse immediately .Document Change in Skin Condition in PCC using Stop-N-Watch Tool .Charge Nurse to report New or Worsening wounds to Physician/NP to receive wound care orders immediately .Charge Nurse should place call to DCS (Director Clinical Services) or ADCS (Associate Director Clinical Services) to inform of New or Worsening wound identified. An IJ was identified on 4/1/2024 and the facility administrator was notified at 7:00pm. The IJ template was provided to the facility on [DATE] at 4:14pm. On 4/3/2024 at 4:40pm the following Plan of Removal was accepted. On 2/19/2024, an impromptu Quality Assurance Performance Improvement (QAPI) Meeting was completed with the Healthcare Administrator (HCA), Director of Clinical Services, Assistant Director of Clinical Services (ADCS), and Medical Director via the phone related to the Skin Management Process related to Resident # 1 skin documentation. The additional actions included re-education to Certified Nursing Assistance (C.N.As) and Licensed Nurses on repositioning and abuse neglect reporting. Re-education for Licensed Nurses on skin assessments, Skin observation protocol (which includes notification of healthcare provider), repositioning, and wound prevention. These Inservice's were completed on 2/20 by the ADCS. On 2/20/2024, the ADCS and Attending Physician assessed the wound to Resident #1's sacrum and new orders received by the attending physician for medical honey and calcium alginate, supplements, and a low air loss mattress. On 2/22/2024 the Third Party Wound Doctor assessed the sacral wound; orders were updated to include Santyl. On 2/22/24, the ADCS performed wound rounds on current residents with wounds. No new pressure concerns were noted. On 3/2/24, Resident # 1 discharged from the community. On 3/13/24, an Impromptu QAPI Meeting held with the HCA, ADCS, Regional Director of Clinical Services (RDCS), and the Medical Director via the phone related to the Skin Management Process. The additional actions included the ADCS or designee to extend the audits of 5 residents dressing to be completed weekly for 90 days, review residents that would benefit from a Low Air Loss Mattress, complete skin checks on current residents, and re-education to C.N.A's and Licensed Nurses to notify the DCS or ADCS on new pressure ulcers. On 3/13-3/14/24, the ADCS and/or designee completed skin checks on current residents. No new pressure concerns were noted. On 3/14/24, a Registered Nurse (RN) performed a remote Skin Documentation Audit. The audit included the following items. The audit was documented on an audit form. o Weekly Skin Integrity Review form to ensure every resident had either the weekly skin form or the section completed in the Nursing Admission Data Collection form, if newly admitted . o That every resident had a weekly skin integrity review activated schedule to be completed weekly in PCC. Form scheduled as needed in PCC. o Weekly Wound Data Collection form if completed, the date, and information in the form. o Third Party Wound Care MD notes in PCC Miscellaneous tab with notes on wounds (location, etc.) o Third Party Wound Care MD orders from their notes on wounds from bullet above. o Physician orders written in PCC for wounds, or anything related to skin. o Care Plans related to wounds. Plan for Compliance From 3/13/- 3/16/2024, the DCS or designee re-educated all Licensed Nurses on change of condition documentation which includes notifying physician and representative, skin documentation, obtaining orders for any wounds, reviewing and addressing clinical alerts on skin concerns from C.N.A's, notifying provider as indicated, professional standards of wound care, that the C.N.A can't apply a treatment, Braden Scale which includes preventative measures. Licensed nurses not available between 3/13/2024 to 3/16/2024 received re-education by the DCS or designee before their next scheduled shift and this will include new hires hired after 3/16/2024. Competency validated with a post test. From 4/1 -4/3 the DCS or designee re-educated nurse on physician notification of new skin issues, change of condition documentation, aides performing dressing changes, skin observation and wound prevention protocol. Licensed nurses not available between 4/1 to 4/3 will receive re-education by the DCS or designee before their next shift, this will include new hires hired after 4/3. Competency validated with a post test. Starting 3/14/24, the Licensed Nurses will initiate the wound data collection sheets on any new pressure ulcers. The RAI or designee will update resident care plans as needed as new pressure concerns arise. The Licensed Nurse will review the clinical alerts in the dashboard periodically through the shift to verify that any new skin concerns communicated by the C.N.A are addressed. The ADCS or designee overseeing will complete the weekly wound data collections for residents with new pressure ulcers until pressure ulcer is resolved or the resident is discharged . Order listing report, progress notes, weekly skin and wound documentation is reviewed during daily standup for any new or worsening pressure ulcers. From 3/13- 3/16/24, the ADCS or designee re-educated all C.N.A.s on communication of changes in skin integrity with the licensed nurse and DCS or ADCS, documentation of any new skin concerns in the electronic medical record every shift including the stop and watch, what to do if dressing falls off the resident's wound, moisture barriers, and turning and repositioning. The C.N.A may complete a Stop and Watch Alert that there is a Change in skin color or condition as indicated. These alerts display on the licensed nurse clinical alert dashboard in the electronic medical record. The C.N.A will also communicate verbally to the licensed nurse what they documented in the electronic medical record related to new skin concerns. The C.N.A. will contact the DCS, ADCS, or the Healthcare Administrator to report new skin issue for additional follow up. C.N.A s not available between 3/13- 3/16/23 received re-education by the DCS or designee before their next scheduled shift and this will include new hires hired after 3/16/24. Competency validated with a post test. From 4/1 to 4/3 C.N.A. were re-educated on C.N.A. not performing dressing changes and are allowed to apply barrier cream, reporting changes in skins and wound prevention. Aides not available between 4/1 to 4/3 will receive re-education by the DCS or designee before their next shift, this will include new hires hired after 4/3. Competency validated with a post test. For 90 days, the DCS or designee will review clinical alerts in stand-up meeting five days a week, to determine if there is documentation of new skin concerns noted by a C.N.A. and verify that appropriate follow up and documentation was completed by a licensed nurse as indicated. The licensed nurses will review clinical alerts including the stop and watch periodically through their shifts daily, to assist with identification of new skin concerns documented by the C.N.A's. For 90 days, the ADCS or designee will audit the weekly skin integrity review for 5 residents a week to verify completion, validate accuracy with a head-to-toe skin check, confirm that appropriate skin care orders are in place as applicable, and notification of the Healthcare was completed as applicable if skin concerns identified. These audits will be documented on an audit form. For 90 days, the ADCS or designee will audit 5 residents' wound care orders a week to verify treatments were completed per physician orders. These audits will be documented on an audit form and reported in the next morning stand up meeting. For 90 days, the DCS or designee will review the audits monthly at the QAPI meeting. Compliance date: 4/3/2024 The surveyor monitoring was from 4/1/2024 to 4/4/2024. Record review on 3/13/2024 revealed a QAPI sign in sheets for 2/19/2024, 3/13/2024, 3/15/24, 3/20/2024, 3/27/2024 with sign in sheets in IJ book by Administrator, Infection preventionist/ADON, Medical Director (3/15/2024). Record review on 3/13/2024 of nurse's notes dated 2/20/2024 revealed the physician was notified immediately on 2/20/2024 at 1:51pm and orders implemented for wound care and wound care physician consulted. Record review on 3/13/2024 revealed staff in-services 2/20/2024 for Abuse and Neglect, the facility provided a copy of policy, Offloading and Repositioning, Skin observation and repositioning, 2/21/24 In-service included Hand Hygiene, Incontinent Care Cleansing, Signs and Symptoms of wound infection, Cleansing of Shared equipment, Handouts: Charge nurse responsibilities, Nursing Forms, Shift Report, Patient appointments and facility provided policy on infection control. Inservice 3/1/2024 Charge nurse responsibilities, 3/13/2024 Reporting new or progression of wound, 3/21/2024 Wound care paperwork, 3/25/2024 Infection Control. Facility provided policy. 3/25/24 Order Confirmation from Physician/NP. Record review on 3/13/2024 revealed wound care physician visit on 2/22/2024 Record review on 3/13/2024 of physician orders dated 2/23/2024 15:00 were updated to include Santyl Ointment as part of the residents wound care regimen. Record review on 3/13/2024 revealed staff were in-service 3/13/2024 Reporting New or Progression of Wound: CNAs t report new or worsening wounds to charge nurse immediately, Charge nurse to report new or worsening wounds to Physician/NP to receive wound care orders immediately, Charge nurse should place call to Director of Clinical Services or Assistant Director of Clinical Services to inform of New or worsening wound identified. Record review on 3/13/2024 revealed skin assessments performed on 2/21/2024 to 2/23/2024 and 3/13/2024. Record review 4/3/2024 revealed Woundcare Orders and Treatment audit to for March 2024 Record review on 4/3/2024 revealed staff were in-serviced 4/2/2024 and 4/3/2024 for Physician notification for new skin issue, change of condition documentation, and CNAs and dressing changes. In-service included CNAs should never apply Zinc oxide to patients' body, change a wound dressing and if the dressing comes off during a shower or bath the CAN needed to notify the nurse to put a new dressing on the wound. The in-service was followed by a post test for CNA's. Record review on 4/3/2024 revealed staff were in-serviced 4/2/2024 for Skin observation/Wound prevention; facility provided policy. Record review on 4/3/2024 revealed audits on 4/2/2024 for residents admitted within the last 30 days for new pressure ulcers and notification to healthcare provider. Audit consisted of reviewing the weekly skin integrity forms, admission assessment and weekly wound data forms. Wound physician progress notes as indicated. No additional findings. Record review on 4/3/2024 revealed weekly skin integrity reviews for February 2024 and March 2024 revealed no new or worsening wounds. Observation of wound care on 4/3/2024 11:45am on Resident #6. Resident #6 noted to be on a low air loss mattress. Nurse washed hands, donned gloves, removed dressing, removed gloves, applied hand sanitizer .donned gloves, wiped wound from inside to outside with gauze impregnated with wound cleanser, removed gloves, hand sanitizer, donned gloves, patted are around wound for adhesion, removed gloves, hand sanitizer, applied calcium alginate and bordered dressing. Dated. Noted wound was healthy and healing, It appeared sacral wound had been larger at one time but now wound small, healthy red with granulation tissue. In an interview on 4/2/2024 at 12:47pm LVN E said she had been in-serviced a few times on wounds and wound care, she said she had been in-service the previous night on reporting new wounds to the physician, letting the unit manager and ADON know, calling the physician for orders and letting them know about changes in condition and weekly skin data. Interview on 4/2/2024 at 12:53pm CNA P said she was not supposed to change dressings on a resident, she said she was supposed to report missing or damaged dressings to the charge nurse or DON and document in the system who she told. Se said she would have reported skin breakdown to the charge nurse or DON, she said she had been in-service today, last week on wounds, change of condition, not to use zinc oxide and moisture barrier. Interview on 4/2/2024 1:00pm CNA Q said he had been in-service on wounds and wound care that morning. He said reporting wounds, new skin issues, not to change dressings, role as a CNAs, and when he saw redness or wounds to report and document in the system. He said he would have reported to the nurse and ADON. Interview on 4/2/2024 at 1:05pm CNA R said she had been in-service that day on what to do and what not to do with wounds and who to report them to. She said not to have changed dressings and not to apply Zinc Oxide. She said they were in serviced on reporting wounds to the nurse or DON and documenting in PCC system. Interview on 4/2/2024 at 1:30pm LVN F said he had been in-service on 4/1/2024 on wound care, who to notify, progress notes, handwashing, and infection control. He said he would have initially let the primary physician and the wound physician know about the wound. He said when a resident had a wound to let the doctor know and get orders and follow them, he said he would have let the DON and unit manager know. In an interview on 4/2/2024 at 1:50pm CNA S said he had been in-service on wounds and wound care. He said CNAs were not to change dressings and not to use ZINC. He said they were supposed to report wounds to the nurse, the ADON and document in PCC. Interview on 4/2/2024 at 2:00pm RN T [TRUNCATED]

Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care in accordance with professional standards of practice the comprehensive person-centered care plan and the resident's choices 1 of 5 residents (Resident #1) reviewed for quality of care. -The facility failed to enter orders for blood sugar monitoring for Resident #1, who had type 2 diabetes, upon admission and as a result the resident's blood sugar was not assessed for over 22 hrs. (01/17/24 at 02:50 PM to 01/18/24 at 01:11 PM) after admission. This failure could place residents at risk of delayed identification/treatment of acute health conditions and hospitalization . Findings Include: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24. Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia. Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital. Record review of Resident #1's Pre-Admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels. Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM. Record review of Resident #1's Admission assessment dated [DATE] at 06:07 PM and signed by LVN A revealed, a diagnosis of type 2 diabetes and there was no documented blood sugar level on admission. Record review of Resident #1's Order Summary Report dated 01/17/24 printed by LVN A and signed by the MD revealed, no orders for blood sugar monitoring. Record review of Resident #1's Order Summary Report dated 01/23/24 revealed, check blood sugars before meals and at bedtime entered on 01/18/24 and started on 01/18/24 at 09:00 AM, over 12 hours after admission to the facility. Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM. - 311 mg/dL on 01/18/24 01:11 PM documented by LVN B. - 207 mg/dL on 01/18/24 05:52 PM documented by LVN D. - 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D. An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted she did not have her blood sugar checked even though she ate meals. Resident #1 said the day after she admitted was the first day she had her blood sugar check but she denied any symptoms or side effects of high blood sure. In an interview on 01/23/24 at 02:35 PM, the DON said when a resident arrives at the facility, they were immediately placed in a room with the staff assisting the paramedics. She said the admitting nurse then completed a head-to-toe assessment, collected vitals (including BS for diabetics) reconciled medications and then contacted the physician to approve all medications and care records. The DON said per the EMR Resident #1 admitted to the facility at 02:50 PM and LVN A completed Resident #1's admission assessment after she arrived at her shift which usually starts between 4 and 5. In an interview on 01/23/24 at 05:11 PM, LVN A said she had been in her role as the admission nurse for the past 3 years. She said when a resident admitted to the facility the nurse who received them was responsible for verifying the residents' medications/orders with the admitting physician and checking vitals which included blood sugar checks. LVN A said she saw Resident #1 when she arrived at her evening shift, the resident was primarily Spanish speaking and arrived at the facility with family. She said she was not the nurse who received the resident, and it was not her responsibility to enter the resident into the system, complete the admitting assessment or check the resident's vitals. LVN A said it was the responsibility of the actual nurse who admitted the resident and the unit manager to ensure all orders were entered and vitals like BS were checked. LVN A said even though she did not actually assess the resident or reconcile the medications/order with the physician, she helped enter the resident's admission assessment and orders a little after six. She said she did not know why she did not enter Resident #1's BS monitoring orders and failure to check blood sugars in a diabetic could place the resident at risk for unidentified hypo or hyperglycemia (low and high blood sugars). In an interview on 01/24/24 at 09:35 AM, the DON said the nurse who received Resident #1 was responsible for checking vitals, which included blood sugars in diabetics, going over the medications and orders with the physician and then entering the orders in the system. The DON said after reviewing the chart, LVN B was the nurse who received Resident #1 but since the resident arrived during a shift change his unit manager should have been responsible for entering the resident's orders into the system. She said she could not determine which nurse reconciled the medications and orders with the physician from the records provided. In an interview on 01/24/24 at 10:01 AM, LVN B said when resident arrived at the facility the admitting nurse was whoever received the resident. He said the admitting nurse was responsible for ensuring that the resident was comfortable, educated about the facility and collecting vitals, reconciling medications with the physician and then entering orders. LVN B said upon admission, the admitting staff must check a diabetic resident's blood sugars immediately to establish their baseline if they did not receive BS records from the discharging facility. He said facility's policy required all new admissions that arrived after 02:00 PM would be given to the unit manager and Unit Manager A was responsible for admitting Resident #1. LVN B said LVN A was the facility admission nurse, and her shift usually began between 04:00-05:00 PM and she would complete admissions of residents who arrived during her shift. In an interview on 01/24/24 at 11:42 AM, Unit Manager A said she was the 2nd floor unit manager, and her shift was from 08:30- 05:00 PM. She said when a resident admitted into the facility, the admitting nurse was responsible for greeting the resident, reconciling medications, verifying orders with the physician and then entering the orders. Unit Manager A said all diabetic residents should have admitting orders to check their blood glucose and lab orders for A1c. She said failure to enter BS orders and check blood sugar upon admission could place the resident at risk for unknown low/high BS and a result in the failure to treat these uncontrolled blood sugars. Unit Manager A said after reviewing the EMR, Resident #1's order entry was her responsibility but LVN B, the admitting nurse, was responsible for checking the resident's BS since it was part of the vitals collected. Unit Manager A said she did not remember processing Resident #1's admission but due to the time the resident arrived it was her responsibility but she was not informed or provided any communication that she had to complete the resident's admission so that was why LVN A completed the admissions assessment and entered the medication orders. Unit Manager A said she could not remember any details regarding Resident #1's admissions. In an interview on 01/24/24 at 12:40 PM, the DON said when Resident #1 admitted to the facility LVN B (the admitting nurse) was responsible for entering orders for BS monitoring and he should have checked the resident's BS upon admission. She said the DON was ultimately responsible for ensuring admissions orders are entered correctly but the responsibility is delegated to the unit managers. The DON said failure enter orders and monitor blood sugars in diabetics could result in a worsening of prognosis as well as hypo and hyperglycemia. In an interview on 01/24/24 at 12:54 PM, LVN B said he did not check Resident #1's blood sugars upon admission or enter her blood sugar monitoring orders and he did not know whose responsibility it was since the resident arrived during a change of shift. An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. Record review of the facility policy titled Blood Glucose Management revised 10/2016 revealed, program overview- charge nurses will provide blood glucose management per Health Care Provider's order.

Based on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for pharmacy services. - The facility failed to acquire and administer antibiotics antidiabetic medications timely to Resident #1 upon admission resulting in the resident's blood sugar level at 311 mg/dL. This failure could place residents at risk of not having their diseases treated, adverse events and hospitalization . Findings Included: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24. Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia. Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital. Record review of Resident #1's Pre-Admission Nursing Report dated 01/17/24 at 01:00 PM revealed, Resident #1 had diabetes and her expected arrival time to the facility was 02:00 PM. There was no documented blood sugar levels. Record review of Resident #1's Census List revealed, Resident #1 admitted to the facility on [DATE] at 2:50 PM. Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed, - Cefdinir (an antibiotic) 300 mg- 1 capsule by mouth every 12 hours for 5 days, with a start date of 01/18/24. - Metformin (an oral antidiabetic) 1000 mg- 1 tablet by mouth two times a day for diabetes with a start date of 01/18/24. - Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24. - Tresiba Insulin- Inject 30 units under the skin every 12 hours for type 2 diabetes with a start date of 01/17/24. - Gabapentin 300 mg- 1 Capsule by mouth two times a day for nerve pain with a start date of 01/18/24 at 09:00 AM. Record review of Resident #1's Blood Sugar Summary dated 01/23/24 revealed, the first documented blood sugar reading was on 01/18/24 at 01:11 PM. - 311 mg/dL on 01/18/24 01:11 PM documented by LVN B. - 207 mg/dL on 01/18/24 05:52 PM documented by LVN D. - 115 mg/dL on 01/19/24 at 10:49 PM documented by LVN D. Record review of Resident #1's 01/17/24 MAR revealed, - Cefdinir 300 mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. - Gabapentin 300mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. - Metformin 1000mg was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. - Tresiba Insulin was not administered on 01/17/24 even though it was scheduled for 09:00 PM for reasons not documented. - Insulin Lispro was not administered on 01/17/24 because it had a scheduled start of 01/18/24 at 09:00 AM. Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed, - Metformin 1000 mg was first administered on 01/18/24 at 11:26 AM. - Cefdinir 300 mg was first administered on 01/18/24 at 11:26 AM. - Insulin Lispro was first administered on 01/18/24 at 01:11 PM. - Tresiba Insulin was first administered on 01/18/24 at 01:11 PM. - Gabapentin was first administered on 01/18/24 at 11:26 AM. Record review of the facility automated dispensing machine inventory list presented on 01/23/24 revealed, - the facility had 10 capsules of Cefdinir 300 mg capsules on hand for emergency dispensing or newly admitted residents. - the facility had 6 capsules of Gabapentin 300 mg capsules on hand for emergency dispensing or newly admitted residents. - the facility did not have Tresiba or Insulin Lispro on hand for emergency dispensing or newly admitted residents. Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, - Tresiba Insulin was first delivered to the facility on [DATE] at 11:59 PM. - Metformin 1000mg was first delivered to the facility on [DATE] at 11:59 PM. - Gabapentin 300 mg capsules was first delivered to the facility on [DATE] at 11:59 PM. - Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send. In an interview on 01/23/24 at 01:23 PM, the ADON said the facility received 3 different pharmacy deliveries. She said the pharmacy delivered medications to the facility in the early morning, mid-day and at night but there was always an option for a STAT delivery to be made within 2 hours for any urgent medications that the facility did not have in their automated dispensing system. The ADON said the facility did not have any insulin on hand for newly admitted or emergency medication orders. An observation and interview on 01/24/24 at 11:00 AM revealed, Resident #1 lying in bed in no immediate distress. She said the day she was admitted (01/17/24) she did not her medications. Resident #1 said she did not receive her antibiotic, Gabapentin and antidiabetic medications (Metformin and Insulins) on 01/17/24 but she did not suffer from any pain or signs/symptoms of uncontrolled blood sugars. In an interview on 01/23/24 at 02:35 PM, the DON said per the EMR, Resident #1 admitted to the facility at 02:50 PM but her medication orders were not entered until after 06:00 PM. She said when a resident arrived at the facility their medication orders should be started immediately to avoid any missing doses based on the hospital discharge medication list. The DON said the facility had an automated dispensing system that could provide initial doses of medications for new admissions and any unavailable medications like insulin could be acquired within 2 hours from the pharmacy through a STAT order. She said if the pharmacy was unable to deliver the medication immediately, the resident's provider should be contacted for an alternative regimen and all medication issues should be documented in the resident's chart. The DON said failure to administer medications immediately upon admission could result in increased blood sugar, increased pain, as well as worsening of infection and hospitalization . In an interview on 01/23/24 at 05:11 PM, LVN A said she has been in her role as the admission nurse for the past 3 years. She said when a resident arrived at the facility the nurse should reconcile the medications against the discharging facility medication lists and medications should be administered based on the last administered dose. LVN A said since Resident #1 arrived at 02:50 PM she should have received her first dose of medications starting that evening and did not know why she entered Resident #1's medications to start the next morning. She said the facility had an automated dispensing system that had the necessary oral medications on hand and the insulin could have been received within 2 hours through a STAT order from the pharmacy. LVN A said she did not know why she did not get the medication from the automated dispensing system, or from the pharmacy and she did not know why she did not document the issue in the resident's progress notes. LVN A said the doctor did not give her approval to delay the start of Resident #1's medications and failure to administer medications immediately upon admission could place residents at risk for uncontrolled health conditions, uncontrolled blood sugars, uncontrolled pain and hospitalization . She said Resident #1 should have received her first dose of medication the night she arrived at the facility. In an interview on 01/24/24 at 12:40 PM, the DON said she was ultimately responsible for ensuring medications were started immediately upon admissions and administered as ordered but that responsibility was delegated to the managers who complete next day audits. She said to her knowledge no one had noticed that Resident #1 was not administered medications upon admissions and her first doses were administered late in the afternoon the next day. The DON said Resident #1, the resident's family as well as her doctor was notified of the missed medications and the resident reported no side effects and the physician did not give any new orders. An attempt was made on 01/23/24 at 03:12 PM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. An attempt was made on 01/24/24 at 09:19 AM to contact Resident #1's Physician. The prescriber was unavailable, and a message was left. Record review of LVN A's Charge Nurse Orientation Checklist-Skilled Nursing signed on 09/01/20 revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. Record review of the facility policy titled Reconciliation of Medications od Admission/Re-Admission and Monthly Orders revised 03/2019 revealed, policy overview- the charge nurse will perform medication reconciliation upon admission, readmission or transition of care from prior levels of care, for the purpose of providing an accurate and current medication regimen. I(B)- Medication reconciliation reduces medication errors and enhances resident safety during the admission/transfer process by: identifying the medications the resident needs and administering without interruption, the correct dosages and routes. Record review of the facility policy titled Receipt of Interim/Stat/Emergency Deliveries revised 01/01/22 revealed, 1- facility should immediately notify pharmacy when facility receives from a physician/prescriber a medication order that may require an interim/stat/emergency delivery. 2. If a necessary medication is not contained within Facility's interim/stat/emergency supply, and Facility determines that an interim/stat/emergency delivery is necessary, Facility should arrange with Pharmacy for one of the following actions: 2.1 For Pharmacy to include the interim/stat/emergency medication(s) in an earlier scheduled delivery or a special delivery, as required, or 2.2 For Pharmacy delivery by contract courier, or 2.3 For Pharmacy to arrange for the medication to be dispensed and delivered by a Third Party Pharmacy to ensure timely receipt.

Based on observation, interview and record review, the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurately documented for 1 of 5 residents (Resident #1) whose records were reviewed for resident identifiable records. - The facility failed to completely and accurately document administration of medication to Resident #1 by documenting administration of Insulin Lispro that was not in the facility and did not occur, This failure could place residents at risk of having incomplete or inaccurate records and inadequate care. Findings Included: Record review of Resident #1's Face Sheet dated 01/23/24 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses of: left hip fracture, overactive bladder, high cholesterol, difficulty swallowing and type 2 diabetes. Resident #1 transferred to facility after a hospital stay from 01/04/24 to 01/17/24. Record review of Resident #1's undated Care Plan revealed, focus- diabetes; goal- the resident will have no complications related to diabetes; intervention- medication as ordered, monitor/document/report to MD s/sx of hypo and hyperglycemia. Record review of Resident #1's Entry MDS dated [DATE] revealed, Resident #1 admitted to the facility from a short-term general hospital. Record review of Resident #1's Order summary dated 01/17/24 at 06:48 PM generated by LVN A revealed, - Insulin Lispro- Inject 10 units under the skin three times a day for diabetes with a start date of 01/18/24. Record review of Resident #1's 01/17/24 MAR revealed, - Insulin Lispro was administered on of 01/18/24 for scheduled doses at 09:00 AM and 01:00 by LVN B. Record review of Resident #1's Medication Administration Audit Report from 01/17/24 to 01/18/24 revealed, - Insulin Lispro was first administered on 01/18/24 at 01:11 PM for the doses scheduled at both 09:00 AM and 01:00 PM. Record review of Resident #1's Pharmacy Records dated 01/24/24 revealed, - Insulin Lispro was first delivered to the facility on [DATE] at 07:29 PM. Insulin Lispro was delayed and did not arrive at the facility until the evening of 01/18/24 because it was held up in billing and read the drug exceeded the facility high dollar limit and required approval due to cost. Need authorization to send. In observation on 01/24/24 at 12:14 PM, inventory of the nursing cart with LVN B revealed, an Insulin Lispro pen labeled for Resident #1 with the facility open date of 01/19/24 on both the pen and on the pharmacy label. Inspection of the 2nd floor medication room with LVN B revealed, no other insulin pens for Resident #1 in the fridge. In an interview on 01/24/24 at 12:40 PM, the DON said staff were expected to document accurately and timely and any discrepancies should be documented in the progress notes. She said Resident #1's insulin arrived on 01/18/24 at 11:59 PM and based on the residents EMR it was not possible for LVN B to administer the 09:00 AM and 01:00 PM scheduled doses of Insulin Lispro to Resident #1 on 01/18/24 at 01:11 PM because the medication was not available in the pharmacy at that time and the facility did not have any insulin on-hand for emergency dispensing. The DON said failure to document accurately placed residents at risk for inaccurate medical records and unidentified missed doses. In an interview on 01/24/24 at 12:54 PM, LVN B said to his knowledge Resident #1 did not have any insulin missing and he did not remember administering Resident #1's insulin late at 01:11 PM on 01/18/24 even though it was the documented time on the MAR. LVN B said the only insulin pen Resident #1 had was the pen observed in the nursing cart with an open dated of 01/19/24 and he could not explain where the insulin he documented as administered came from since the pen had not arrived at the facility at the documented time of administration. When asked about the requirement of accurate and timely documentation, LVN B could not provide an answer. He said he did not remember any specifics about Resident #1's Insulin Lispro pen and medication administration time and when asked how he documented the administration of medication that was not available he said I also want to know what happened with the medication and the documentation. He could not provide any details regarding the discrepancy between the documentation and the unavailability of the medication. Record review of LVN B's Charge Nurse Orientation Checklist-Skilled Nursing signed on 04/24/22 by the ADON revealed, training on entering orders into the EMR, documentation administration of medications and treatment in the EMR, medication reconciliation, order and receiving medications electronically and emergency kits was completed. Record review of the facility policy titled Medication Administration revised 12/2020 revealed, after administering/observation of the client taking the medication the staff must sign for the scheduled assistance time and date for medications and if applicable, the associate should document the refusal or reason for not administering medication as ordered. Record review of the facility policy titled Documentation for Skilled Services revised 05/2023 revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times. Record review of the facility provided Skilled Documentation Guide with no revision date revealed, no specific instructions on the accuracy and timeliness of documentation and medication administration times.

Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice to promote healing, prevent infection and prevent ulcers from developing for 1 (Resident #2) of 11 residents reviewed for treatment of pressure ulcer. -The facility failed to provide treatment in a timely manner for Resident #2 who experienced a decrease in skin integrity to the sacral region that resulted in an unstageable wound to the sacral region diagnosed by the wound care doctor on 12/1/23. -The facility failed to do consistent weekly skin assessments on Resident #2. -Facility failed to change Resident #2's dressing to sacrum on 12/06/2023 as ordered by the wound care doctor. These failures could place resident (s) who have wounds and at risk for skin impairment at risk for further decrease in skin impairment issues, infections, possible hospitalization , and decrease in quality of life. Findings: Record review of Resident #2 face sheet revealed an 81year old male admitted to the NF on 11/06/23. Resident #2 diagnoses included the following: Urinary Tract Infection, Klebsiella Pneumonia (bacteria), gastroenteritis (intestine infection) and colitis (inflamed colon), type 2 diabetes mellitus, moderate protein-calorie malnutrition, chronic kidney disease stage 4, hypertension (high blood pressure), anemia (low blood), muscular weakness, benign prostate hyperplasia (age associated prostate gland enlargement) and acquired absence of right leg below knee. Record review of Resident #2 MDS dated [DATE] revealed that resident BIMS score was 11 indicating resident cognition was moderately intact. Further review reveled that resident was dependent of toilet hygiene, had an indwelling catheter, and was always incontinent of bowel. Further review revealed that resident had a diabetic pressure ulcer and was at risk for developing pressure ulcers/injuries. Record review of Resident #2's Care Plan dated 11/06/23 and revised on 12/07/23 revealed that resident was being care planned for impairment of skin integrity diabetic ulcer to left lateral ft stage 3 left heel and unstageable to sacrum. Resident interventions included the following: assist with turning and reposition as needed, Braden scale as required, evaluate skin condition on a daily and weekly basis, low air mattress, and monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD. Record review of Resident #2's Braden scale (Predicting Pressure Ulcer Risk) dated 11/13/23 revealed that resident score was 15 indicating that resident was at mild risk for skin breakdown documented by the ADON on 11/14/23. Record review of Resident #2's Physician Order Summary Report included the following orders: -Dated 11/13/23, Apply skin prep to L (left) lateral foot every evening shift for 30 days -Dated 11/20/23, Santyl Ointment 250 unit/gm (collagenase) apply to left heel topically every evening shift for wound care cleanse with wound cleanser, pat dry, apply santyl to necrotic area, apply calcium alginate, apply dry gauze island w/bdr dressing (with border dressing). -Dated 12/01/23, Santyl Ointment 250 unit/gm (Collagenase) apply to unstageable sacrum topically every evening shift for wound care cleanse sacral wound with wound cleanser, pat dry, apply santyl to necrotic area, apply calcium alginate, apply gauze island bdr dressing. -Further record review of Resident #2's Physician orders did not reveal orders for pain Record review of Resident #2's Weekly Skin Assessment revealed the following: -Dated 11/09/23 Assessment revealed wound to left heel (pressure wound) -No assessment done 11/16/23 -Dated 11/20/23 Assessment revealed wound to left heel (pressure wound) -Dated 11/27/23 Assessment revealed wound to left heel -Dated 12/07/23 Assessment revealed wound to left heel (stage 3 pressure wound of the left heel full thickness diabetic wound of the left heel, Sacrum (unstageable due to necrosis sacrum full thickness) Record review of Resident #2's CNA Shower Skin Check Sheet revealed that CNA B documented the following: -Dated 11/21/23 Resident with skin redden to scrotum and skin breakdown to sacrum and left heel signed by LVN I -Dated 11/23/23 Resident #2 with redden scrotum and skin breakdown to sacrum and bandage on sacrum signed by LVN I -Dated 11/28/23 Resident #2 with redden scrotum, left heel and sacrum wound, signed by LVN I Record review of Resident #2's Wound Evaluation & Management Summary documented by the Wound Care Doctor revealed the following: -Dated 11/10/23 Stage 3 pressure wound of the left heel full thickness, wound size (L x W x D) 4.7 x 3.5 x 0.2 cm. Surface area 16.45cm, exudate (drainage) moderate serous (pale yellow watery fluid). -Dated 12/01/23 Stage 3 pressure wound left heel full thickness, wound size (L x W x D)3.6 x 5.2 x 0.1cm, surface area 18.72cm with moderate exudate. -Dated 12/01/23 Unstageable (due to necrosis- dead tissue) wound size (l x W x D) 12.1 x 8.2 x 0.1cm, surface area 99.22cm, exudate moderate serous, thick adherent devitalized necrotic tissue 70 %. Surgical excisional debridement (removal of damage tissue) procedure indication: remove thick adherent (sticking fast to an object or surface) eschar (collection of dry, dead tissue within a wound) and devitalized tissue (dead tissue cells). Record review of Resident #2' TAR for the month of December 2023 on the 6th revealed that resident dressing to the left heel and sacral wound was not documented as done. Further record review for the months of November and December 2023 revealed that the facility was doing pain assessment on resident with no pain documented. Interview on 12/07/23 at 11:10AM the DON said the facility wound census she would have to confirm with the ADON on the phone with at present time. The DON said the facility wound census was 9 and that the facility had one resident with an acquired wound and that was Resident #2. The DON said Resident #2 had acquired a wound to his sacrum that was unstageable. Observation on 12/07/2023 at 12:30PM Resident #2 was in bed on an air mattress that was fully inflated. Resident had an indwelling Foley catheter draining clear yellow urine. Further observation was made of residents right leg which was amputated below the knee. Further observation was made of resident dressing to the sacrum which was dated 12/05/23. The surveyor did not observed resident Left lower extremity at this time due to not being aware that resident had a wound to the heel. Interview on 12/07/23 at 12:30PM with Resident #2 said he was not in any pain. Observation on 12/07/2023 beginning at 12:35PM of dressing change for Resident #2 sacrum wound by LVN I. LVN I sanitized a bedside table to place resident dressing supplies on. LVN I washed her hands with soap and water and proceeded to remove resident old dressing. LVN I confirmed that the date on resident sacrum read 12/05/23. LVN I said resident dressing to the sacrum was supposed to be changed on the evening shift. Observation was made of resident being incontinent of loose stool. Further observation was made of resident sacrum area with skin breakdown large in circumference with variations of redness and sloughing (yellow tissue) of the skin. After LVN I and the (CNA Staffing Coordinator, name unknown) provided incontinent care for resident, LVN I washed her hands again with soap and water and proceeded to change resident dressing to his sacrum. LVN I cleansed the wound site with wound cleanser using a 4 x4's. When LVN I was done cleansing the wound site, she wiped around the wound edges with skin prep. LVN I then applied santyl ointment to yellow tissue of the wound site. LVN I then applied to wound calcium alginate secured with border dressing. Interview on 12/07/23 at 2:12PM RN E said he worked the 3PM-11PM shift. RN E said he was Resident #2's nurse on 12/06/23. RN E said he must have forgotten to change Resident #2's dressings to the sacrum and left heel. RN E said when a resident wound dressing is not changed as ordered by the physician, it placed the resident at risk of the wound getting infected. RN E said he could not remember if he had done weekly skin assessments on Resident #2. Interview on 12/07/23 at 3:00PM the DON said the facility Nursing staff failed Resident #2 because they failed to communicate with one another as well as the Wound Care Doctor when the resident began to experience skin breakdown to his sacrum. The DON said when the wound care doctor started treating the residents wound to the sacrum, it was unstageable. The DON said the resident wound to the sacrum was large. The DON said this failure placed the resident at risk for further infections. The DON said she believed that when the resident was admitted to the facility, he was being treating for a urinary tract infection. The DON said she did not know how well the resident wound to sacrum was going to heal, she just knew that the situation was bad. The DON said all she could do moving forward, was in-service the nursing staff on communicating that whenever a resident experienced a change in condition the nurses must intervene in a timely manner. The DON said the nurses must assess the residents as well as inform the doctor so that a treatment plan can be put in place. The DON said she did not know if the ADON had initiated any in-service when she was informed on last week about Resident #2 skin breakdown to the sacrum. Interview on 12/07/23 at 3:08PM LVN I said she assessed the resident's skin when it was scheduled for her to do so. LVN I said one day a CNA whom she believed was CNA B came to her on the morning shift informing her that Resident #2 had skin breakdown to his sacrum. LVN I said she could not remember if it was last week or 2 weeks ago. LVN I said it was the nurses on the morning and evening shift that were assigned to do weekly skin assessments. LVN I said weekly skin assessments were done on resident in rooms 230-234 by the day nurse. LVN I said residents weekly skin assessments for residents in room [ROOM NUMBER]-240 were done by the nurse on the evening shift. LVN I said on Saturday's resident in room [ROOM NUMBER]-A bed skin assessments were done on the day shift and 242-Bed skin assessment was done on a Sunday on the evening shift. LVN I said Resident #2 resided in room [ROOM NUMBER]. LVN I said a resident that had a wound with a dressing, the dressing should be checked regardless of what shift the nurse was working. LVN I said she had to be honest, she was not checking the wound dressings or resident skin if another nurse was assigned the task. LVN I said the nurse is accountable for their own work. LVN I said moving forward she would ask the DON to see how she wanted to proceed in the matter. LVN I said the more she thought about it, spot checking a resident wound dressing would be a good idea. LVN I said the wound care doctor saw the residents wound today (12/07/23) and did more debridement on Resident #2's wound to the sacrum. LVN I said if a resident dressing to a wound is not changed as ordered, the wound could become infected placing the resident at risk for osteomyelitis an infection that goes to the bone. LVN I said Resident #2 was admitted to the facility with a urinary tract infection and had received antibiotics for it. Interview on 12/07/23 at 3:27PM the Wound Care Doctor said the ADON informed her that Resident #2 had developed a new wound to the sacrum on 11/30/23. The Wound Care Doctor said she assessed Resident #2's sacrum on 12/07/23. The Wound Care Doctor said when she observed resident sacrum, she became frustrated asking the ADON why the facility did not inform her regarding resident skin to his sacrum had broken down? The Wound Care Doctor said she was coming to the facility every week to treat Resident #2's wound to his left heel. The Wound Care Doctor said when she observed resident skin to the sacrum, there was deep tissue injury with necrosis that was unstageable. The Wound Care Doctor said the residents wound to the sacrum looked very bad. The Wound Care Doctor said this was frustrating because the staff had to have observed the skin to resident sacrum deteriorating because they were providing care for Resident #2. The Wound Doctor said this failure had placed the resident at risk for pain, infections, further decrease in mobility, and further clinical deterioration like a [NAME] effect. Interview on 12/07/23 at 3:47PM ADON said Resident #2 skin breakdown to the sacrum was bought to her attention by nurse LVN I and RN E toward the end of the day shift on 11/30/23. The ADON said LVN I reported to her that the resident had something on his bottom. The ADON said when she observed the residents sacrum, she saw a deep tissue injury that covered a large area of resident sacrum, and the color was pink and purple with variations of skin sloughing. The ADON said she cleaned the sacrum site with a wound cleanser and applied calcium alginate to the site because the wound was oozing. When the ADON was asked if she had an order to apply calcium alginate to the site, the ADON retracted her statement and said she had just woken up and that the wound care doctor gave the order on 12/01/23. Interview on 12/08/23 at 9:43AM CNA B said she started noticing skin breakdown to Resident #2's sacrum 2 weeks prior and had informed nurse LVN I and another nurse that worked at the facility PRN. CNA B said LVN I and Clinical Manager C told her to put zinc oxide on the resident skin (skin barrier) and that they would assess the resident skin to his sacrum. CNA B said when she started taking care of Resident #2, he already had a dressing to the sacrum and the left heel. CNA B said she always reported to the nurses whenever a resident experienced any change in condition so she would not get blamed for anything. Interview on 12/08/23 at 9:45AM LVN I said CNA B, she believed, reported to her that Resident #2 had skin breakdown to the sacrum. LVN I said she could not remember when this occurred and did not know if this happened last week or 2 weeks ago. LVN I said CNA B told her that Resident #2's dressing to the sacrum was coming off. LVN I said when she saw resident sacrum, she observed a large area of redness that included skin discoloration with some drainage and variations of skin sloughing but no odor. LVN I said she cleansed the resident sacrum with wound cleanser, covered the wound, and informed the ADON of her findings. LVN I said she never assessed Resident #2's skin because he was not on her assignment for weekly skin assessments. LVN I said RN E was supposed to do Resident #2's weekly skin assessments. Interview on 12/08/23 at 10:05AM the DON said the CNAs were supposed to use the POC (Plan of care) to document any changes in a resident skin. The DON said some of the CNA's still documented on the resident skin shower sheets. The DON said the resident skin shower sheets were not considered a part of the resident records and that the POC was. The DON said the facility used the shower sheets for a in house audit. Interview on 12/08/23 at 2:52PM CNA G said she remembered Resident #2. CNA G said she told RN E about the resident having skin breakdown to the sacrum. CNA G said RN E told her that he would take care of it later. CNA G said she could not remember the day when this happened. Record review of the facility policy on Skin Observation and Wound Prevention Protocol revised 10/22 revealed in part: .Charge nurses should observe the condition of the resident's skin on admission and on routine basis. This system also provides a communication process for the nursing assistant to report residents with skin changes to the Charge Nurse .Weekly: The Charge Nurse should complete the skin Integrity Review form for residents. Document any integumentary findings including the dressing being removed (if indicated), the appearance of the wound, and treatment applied/initiated per health care provider order in the progress notes .The CNA should: complete documentation of new skin concerns as identified in Point of Care and notify the nurses as indicated. Provide showers/baths per preferred routine schedule and as needed. Provide skin care during routine care. Apply moisturizing creams, barrier products per plan of care and scope of practice .

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment including the use of PPE and following CDC guidelines for COVID-19 for 8 of 9 residents (Resident #1, #2, #3, #4, #5, #6, #7, and #9) reviewed for infection control. -The facility failed to establish and maintain an infection control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections. - The facility failed to have PPE 'stations' at the entrance of each of the 17 quarantine rooms for staff to don prior to entering the rooms. -The facility failed to assign designated staff to work only with quarantined residents. The facility had the same staff, one nurse and one CNA per hall, providing care for all the residents, including the quarantine residents, on the hall. -Staff entered quarantine rooms without an N95 or eye protection. -Staff in the facility wore homemade cloth masks. - Quarantined Residents had no Isolation set up in the room for hazardous trash and laundry bins. An Immediate Jeopardy (IJ) was identified on 5/15/2020. While the IJ was removed on 5/19/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate threat and a scope of pattern while they continued to monitor their plan of removal. These failures placed all residents at risk of contracting COVID-19 resulting in possible serious illness or death. Findings Include: Resident #1 Record review of the Admission Record for Resident #1, dated 05/18/20, revealed he was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #1 was discharged from the facility on 05/13/20. Record review of the Care Plan for Resident #1, dated 05/11/20, revealed he was a new admission to the facility and was at risk for COVID-19 exposure. The Care Plan revealed the resident would be managed under a quarantine process with PPE. The Care Plan did not specify which PPE. Observation of Resident #1 in room [ROOM NUMBER] on quarantine on 05/13/20 at 9:37 a.m. revealed Resident #1 was sitting up on the side of the bed. CNA D was in the room. CNA D was observed to have on a mask, but no gloves. She was moving things around in the resident's closet, then handled the resident's oxygen cannula. CNA D then left the room without washing or sanitizing her hands. Continued observation revealed there was an X-ray technician in the room. The X-ray technician was wearing a mask and gloves, but no other PPE. There was no PPE available at the entrance or inside the room, other than gloves. Resident #1's quarantine room was on the 2nd floor among resident rooms of residents who were not on quarantine. Record review of CDC.gov website read in part, .The PPE recommended when caring for a patient with known or suspected COVID-19 includes: · Respirator or Facemask (Cloth face coverings are NOT PPE and should not be worn for the care of patients with known or suspected COVID-19 or other situations where a respirator or facemask is warranted) Put on an N95 respirator (or higher level respirator) or facemask (if a respirator is not available) before entry into the patient room or care area, if not already wearing one as part of extended use or reuse strategies to optimize PPE supply. Higher level respirators include other disposable filtering facepiece respirators, PAPRs, or [MEDICATION NAME] respirators. N95 respirators or respirators that offer a higher level of protection should be used instead of a facemask when performing or present for an aerosol generating procedure (See Section 4). See appendix for respirator definition. Disposable respirators and facemasks should be removed and discarded after exiting the patient ' s room or care area and closing the door unless implementing extended use or reuse. .· Eye Protection *Put on eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face) upon entry to the patient room or care area, if not already wearing as part of extended use or reuse strategies to optimize PPE supply. Personal eyeglasses and contact lenses are NOT considered adequate eye protection. .· Gloves Put on clean, non-sterile gloves upon entry into the patient room or care area. Change gloves if they become torn or heavily contaminated. Remove and discard gloves when leaving the patient room or care area, and immediately perform hand hygiene. · Gowns Put on a clean isolation gown upon entry into the patient room or area. Change the gown if it becomes soiled. Remove and discard the gown in a dedicated container for waste or linen before leaving the patient room or care area. Disposable gowns should be discarded after use. Cloth gowns should be laundered after each use. If there are shortages of gowns, they should be prioritized for: *aerosol generating procedures *care activities where splashes and sprays are anticipated *high-contact patient care activities that provide opportunities for transfer of pathogens to the *hands and clothing of HCP. Examples include: *dressing *bathing/showering *transferring *providing hygiene *changing linens *changing briefs or assisting with toileting *device care or use *wound care . .3. Patient Placement · For patients with COVID-19 or other respiratory infections, evaluate need for hospitalization . If hospitalization is not medically necessary, home care is preferable if the individual ' s situation allows. · If admitted , place a patient with known or suspected COVID-19 in a single-person room with the door closed. The patient should have a dedicated bathroom. · As a measure to limit HCP exposure and conserve PPE, facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with known or suspected COVID-19. Dedicated means that HCP are assigned to care only for these patients during their shift. Record review of CDC Interim Clinical Guidance for COVID-19 Referral policy dated (03/2020) read in part: .Hospital Discharges to Skilled Nursing Community: we strongly urge SNFs to begin now creating separate wings, units or floors by moving current residents to handle admissions from the hospital and keep current resident separate . Interview on 05/13/20 at 9:40 a.m. with CNA D revealed she said the stop sign on the door meant Resident #1 was on quarantine. When CNA D was asked where the PPE for the room was, she then said the resident was no longer on quarantine. Record review of the facility Quarantine List dated 05/13/20 revealed Resident #1 was on quarantine beginning on 5/11/20 through 5/24/20. Resident #2 Record review of the admission sheet for Resident #2 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #2's comprehensive MDS assessment dated [DATE] revealed a BIMS of 02 indicating severely impaired cognition. Resident #2 had short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and he never/rarely made decision. Further review of the MDS revealed that he required extensive assistance from staff for dressing, toilet use, personal hygiene, transfers and bed mobility. Resident #2 had an indwelling catheter and always incontinent of bowel. Section V care area assessment summary revealed Resident had a feeding tube. Record review of the facility Quarantine List dated 5/13/20, revealed Resident #2 was scheduled to come off of quarantine today, 5/13/20. Record review of Resident #2's hospital records testing information revealed Resident #2 was noted as having been tested for COVID-19 on 4/21/20, which was 8 days prior to admission, and 22 days prior to this date of 5/13/20. The documentation of not being tested was in conflict with the facility COVID-19 Resident Screen form. Record review of Resident #2's facility COVID-19 Resident Screen form dated 5/13/20 revealed Resident #2 was documented as not being tested for COVID-19 and was not on droplet or contact isolation precautions. Observation on 5/13/20 at 9:01 am revealed Resident #2's door was opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. This hall had both negative and quarantine rooms on it. There was a sign posted on the Resident's room door STOP see nursing staff that indicated the resident was on isolation precautions. Further observation revealed there were no covered isolation bins in the room for trash or dirty linens to allow for disposal of contaminated items in a controlled manner. CNA A was in the room within 6 feet of the Resident. CNA A was wearing a homemade mask and gloves. Resident #2 had no mask on while the CNA was in the room. In an interview on 5/13/2020 at 9:25 am with CNA A, she said she worked full time during the 6-2 pm shift at this facility. She said due to low resident census there was one nurse and one CNA assigned to each hall. She said residents with a STOP sign on their doors were the residents that had come from the hospital. She said they were in quarantine for 14 days as precaution for COVID signs and symptoms. She said the staff were to wear a mask and gloves while caring for these residents. She said she had a homemade mask on as it was easy to breathe in. She said staff could wear homemade masks or facility provided surgical masks to care for quarantined residents. Record review of website CDC.gov read in part: .HCP use of homemade masks: In settings where facemasks are not available, HCP might use homemade masks (e.g., bandana, scarf) for care of patients with COVID-19 as a last resort. However, homemade masks are not considered PPE, since their capability to protect HCP is unknown. Caution should be exercised when considering this option. Homemade masks should ideally be used in combination with a face shield that covers the entire front (that extends to the chin or below) and sides of the face. Resident #3 Record review of the admission sheet for Resident #3 revealed a [AGE] year-old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3's Admission MDS assessment dated [DATE] revealed a BIMS of 15 indicating intact cognitively. Further review of the MDS revealed that he required extensive assistance from two people for toilet use, transfers and bed mobility. He required limited assistance with dressing, eating and personal hygiene. Resident #3 was frequently incontinent of bowel and bladder. Section O Special Treatments, procedures, and program indicated Resident #3 was on [MEDICAL TREATMENT]. Record review of Resident #3's physician's orders [REDACTED]. Record review of the facility Quarantine List dated 5/13/20 revealed Resident #3 was documented as being a [MEDICAL TREATMENT] resident on indefinite quarantine. Record review of Resident #3's facility COVID-19 Resident Screen form dated 5/11/20 revealed he was documented as not having been tested for COVID-19. He was documented as not being on droplet and contact isolation precautions. Observation on 5/13/2020 at 9:11 am reveled Resident #3's door was opened to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was a sign posted on the Resident's room door STOP see nursing staff which indicated the resident was on isolation precautions. Further observation revealed there were no covered isolation bins in the room for trash or dirty linens to allow for disposal of contaminated items in a controlled manner. Resident #3 was lying in his bed watching TV. His room was not on a designated quarantine hallway. Observation on 5/13/2020 at 9:25 am revealed two EMS personnel were in Resident #3's room assisting the Resident to transfer from the bed to the stretcher. Continued observation on 5/13/2020 at 9:31 am revealed the two EMS personnel brought Resident #3 out of his room on a stretcher to the nurse's station and requested a mask for Resident#3 as he was being transported to the [MEDICAL TREATMENT] center. The Infection Prevention nurse placed a surgical mask on the Resident. Resident #4 Record review of the Admission Record for Resident #4, dated 05/18/20, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan dated (initiated) 05/04/20 revealed the resident was a new admission to the facility and was at risk for COVID-19 exposure. The Care Plan reflected the resident would be cared for managed under a quarantine process with PPE. The Care Plan did not specify which PPE. Observation on 05/15/20 at 1:35 p.m. revealed room [ROOM NUMBER] had a stop sign on the door. Observation revealed Resident #4 was lying in bed. She was awake. She was not wearing a mask. Observation revealed CNA G was sitting in a chair. She appeared to be asleep. The resident called out to her, and CNA G went to the door. Her mask was under her chin, and she had no gloves on. She said she just finished changing the resident. Resident# 5 Record review of the admission sheet for Resident #5 revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #5's Admission MDS assessment dated [DATE] revealed a BIMS of 03 indicating severely impaired cognition. Resident #5 had short term memory problem, long term memory problem, and cognitive skills for daily decision making was severely impaired and he never/rarely made decision. Further review of the MDS revealed that she required extensive assistance from staff for toilet use, transfers and bed mobility, dressing, eating and personal hygiene. Resident #5 was frequently incontinent of bowel and bladder. Record review of the facility Quarantine List dated 05/13/20 revealed Resident #5 was scheduled to be on quarantine from 05/4/20 to 05/17/20. Record review of Resident #5's hospital records revealed her last test date was documented as 4/25/20, 8 days prior to admission to the facility. Record review of Resident #5's facility COVID-19 Resident Screen form dated 5/16/20 revealed she was documented as not being tested for COVID-19 and was not on droplet or contact isolation precautions. Observation on 5/13/2020 at 10:34 am revealed Resident #5's door was opened halfway to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. This room was on a hall with both quarantine and negative rooms. There was a sign posted on the Resident's room door STOP see nursing staff which indicated the resident was on isolation precautions. Further observation revealed a caregiver was sitting on a chair next to the Resident's bed with a surgical mask on. The caregiver was within 6 feet of the resident. Resident #5 was lying in her bed watching TV. In an interview on 5/13/2020 at 10:37 am with RN A, she said Resident#5 had come from the hospital. She was on quarantined for 14 days for COVID precautions. She said Resident #5 had private sitters (caregivers) hired by the facility. When asked about whey the facility COVID-19 Resident Screening documentation did not match what was listed on the Quarantine list regarding whether a resident had been tested for COVID-19 she said the nurses documenting the facility COVID-19 Resident Screening form did not know whether a resident had been tested . Observation and interview on 5/17/2020 at 9:13 am with Caregiver A, revealed she was in full PPE gown, N95 mask, hair covering and booties. She came out of Resident#5's room and grabbed a pair of gloves from the box of gloves sitting on top of the isolation station. She said she was hired by the facility to provide care to Resident#5. She said normally they kept a box of gloves in the resident's bathroom or on top of the night stand. She said she was getting ready to feed the resident and needed a new pair of gloves but there were none in the resident's room. She said she was wearing full PPE as a precaution due to the resident was on isolation/quarantine. In an interview on 5/17/2020 at 9:45 am with the DON, she said there were residents that had private sitters hired by the facility. This Surveyor shared her observations with the DON. The DON said the private sitter needed to press the call light and not come out with PPE on as it caused risk for infection. She said she would in-service all staff. Resident #6 Record review of the admission sheet for Resident #6 revealed a [AGE] years old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #6's Admission MDS assessment dated [DATE] revealed a BIMS of 15 indicating intact cognition. Further review of the MDS revealed that he required limited assistance from staff for toilet use, transfers and bed mobility, dressing, eating and personal hygiene. Resident #6 was frequently incontinent of bowel and had a indwelling catheter. Record review of the facility Quarantine List dated 05/13/20 revealed Resident #6 was scheduled to be on quarantine from 05/09/20 to 05/22/20. Record review of Resident #6's hospital records revealed his most recent testing date was documented as 5/5/20, one day prior to admission to the facility. Record review of Resident #6's facility COVID-19 Resident Screen form dated 5/15/20 revealed revealed the resident was documented as not being tested for COVID-19 and was not on droplet or contact precautions. Record review of Resident #6's care plan initiated on 5/6/2020 and revised on 5/17/20 revealed the following care plan: Focus: Resident #6 is new admission / readmission to the community or was out of the community for a brief period and is at risk for COVID-19 exposure. Quarantine x 14 days (stop 5/23/20). Goal : Resident will be cared for at current health status or improvement in health status. Interventions: COVID-19 monitoring every 8 hrs per standard. New admissions that have not had a negative result on a COVID-19 test will be managed under a quarantine process with use of PPE. Observation on 5/13/20 at 9:34 am revealed Resident #6's door was closed to the hallway with no isolation cart sitting near the door for staff and visitors to have access to personal protection equipment at the entrance to the room. There was a sign posted on the Resident's room door STOP see nursing staff that indicated the resident was on isolation precautions. Observation and interview on 5/17/2020 at 10:01 am revealed Caregiver B wearing a gown, hair covering, and surgical mask. She came out of Resident#6's room and was standing by the isolation station. Caregiver B said she was the private sitter for the resident and was hired by the facility. She said she was out of gloves inside the resident's room and needed a pair of gloves to take the resident to the bathroom. The weekend supervisor and the ADON were passing by and observed Caregiver B standing by the isolation station. The Weekend Supervisor told Caregiver B she could not come out of the room with PPE on. The Weekend Supervisor asked the ADON to get a new box of gloves and discard the box of gloves that Caregiver B reached into as it was contaminated. In an interview on 5/17/2020 at 10:03 am with the Weekend Supervisor, she said Caregiver B should have pressed the call light, it was not acceptable to be out of the room with PPE on. Resident #7 Observation and interview on 05/15/20 at 1:28 p.m. revealed LVN E enter room [ROOM NUMBER], which had a stop sign on the door. She had on a surgical mask but no gloves or eye protection. She administered the medications to Resident #7. Upon exiting the room, LVN E was asked what the stop sign meant, she said the resident was on quarantine for 14 days as a new admission. When asked what PPE staff was supposed to wear in the room, she answered they should be wearing gloves. She acknowledged she was not wearing gloves. Observation and interview on 05/15/20 at 1:30 p.m. revealed CNA F enter room [ROOM NUMBER] with a cup of coffee. She had a mask on, but no gloves or eye protection. When she exited the room, she was asked what the stop sign meant. She said the resident recently came from the hospital, and staff were to wear a mask, gloves, and a gown. When asked why she did not have gloves on when she entered the room, she said she could not walk in the hall with gloves on. Record review of the facility Quarantine List dated 5/13/20 revealed Resident #7 was on quarantine beginning on 5/7/20 through 5/21/20. Record review of Resident #7's hospital records revealed a test date of 4/22/20. Resident #9 Record review of the Admission Record for Resident #9, dated 05/18/20, revealed she was [AGE] years of age, and was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Record review of the Care Plan for Resident #9, dated 05/06/20, revealed he was a new admission to the facility and was at risk for COVID-19 exposure. The Care Plan reflected the resident would be cared for managed under a quarantine process with PPE. The Care Plan did not specify which PPE. Interview on 05/13/20 at 10:00 a.m. with CNA C she said when residents came from the hospital they were placed on quarantine for 14 days. CNA C was standing in front of room [ROOM NUMBER], which had a stop sign on the door. When asked if the resident (Resident #9) was on quarantine, CNA C said the resident had been at the facility for a month and was no longer on quarantine. Record review of the facility Quarantine List dated 05/13/20 revealed Resident #9 was scheduled to be on quarantine from 05/07/20 to 05/20/20. Record review of Resident #9's hospital records revealed her testing date was documented as 5/5/20, 13 days prior to admission. In an interview on 5/13/2020 at 9:20 am with Housekeeping A, she said she worked full time during the 6-3 pm shift. She said STOP signs on the Resident's room door meant the Resident had come from the hospital. She said for precaution from [MEDICAL CONDITION], staff had to wear a mask and gloves. She said she used one cart to clean all of the rooms in her assigned Hall 100. In an interview on 5/13/2020 at 9:24 am with the DON, she said the residents that have come from the hospital had to be quarantined for 14 days. They have stop signs on their doors. She said there was no need for full PPE. She said the staff required only a mask and gloves while caring for those residents. In an interview on 5/13/2020 at 9:31 am with the Infection Prevention Nurse, she said she had provided training to staff on how to don and doff PPE and hand washing with return demonstration. She also educated staff on the different types of infections such as airborne TB and [MEDICATION NAME] and the proper way to reuse a mask. She said the facility had enough PPE and masks on hand. She said no visitors were allowed except for healthcare providers. She said the hospice nurse came to see the hospice residents. They were to be screened at the front door and have a mask on. She said the residents that come from the hospital or appointments were placed on quarantine for 14 days. She said staff were to always wear a mask, sanitize while going in and out of the room and to wear gloves if they are touching/providing care to the residents. Observation on 05/13/20 from 9:32 a.m. to 9:36 a.m. revealed stop signs on the doors of Rooms 211, 222, 229, 234, 235, and 238. Observation revealed there was no PPE available at the entrance or just inside the room, with the exception of gloves. Observation revealed HSKP B in room [ROOM NUMBER]. She was wearing a mask and gloves, but no other PPE. In an interview and observation on 5/13/2020 at 9:38 am with RN A, she said today was her fifth day of orientation on the floor with another nurse. She said during each shift, nurses had to fill out a COVID questionnaire for the residents. She said the residents that come from the hospital were quarantined in their rooms. She said only a mask and gloves were required to care for those residents. She said one of the resident screening questionnaire indicated/asked if the resident was tested for COVID in the hospital. She said most of those residents tested negative prior coming to the facility. She said there was one nurse and one CNA assigned on each side of the hall. She said on Hall 100 there were two residents with private sitters hired by the facility. Observation revealed RN A was wearing a surgical mask. Interview on 05/13/20 at 9:45 a.m. with LVN B revealed she said residents who came from the hospital were to be placed on quarantine for 14 days. She said the resident was to wear a mask, and the staff were to wear a mask and gloves. Observation on 05/13/20 at 9:46 a.m. revealed CNA D enter quarantine room [ROOM NUMBER] with no PPE on other than gloves and a mask. CNA D was within 6 feet of the resident. In an interview on 5/13/2020 at 9:58 am with the DON, she said due to low census only one nurse and one CNA were assigned on each side of the hall. She said there was no designated staff for quarantined residents. Interview on 05/13/20 at 11:50 a.m. with the DON revealed she said when residents came from the hospital they were to be placed on quarantine. She said while a resident was on quarantine, the staff were required to wear a mask and gloves while in the room. She said if the resident became symptomatic, the physician would be called, and the resident would be sent out to the hospital via 911. She said the residents would go to a sister facility upon discharge from the hospital. She said residents who would be placed on isolation would have lab work to indicate why they were on isolation. She said the lab contracted by the facility was capable of COVID-19 testing, but the facility had not tested any residents yet. When asked, she agreed a resident could be a carrier and be asymptomatic, making it possible to spread [MEDICAL CONDITION]. She said the difference between Isolation and Quarantine- Isolation requires labs. Quarantine is only monitoring vital signs and pulse ox. Observation on 05/15/20 at 1:15 p.m. revealed RN D enter quarantine room [ROOM NUMBER] with a water pitcher. She was wearing a mask and gloves, but no other PPE. CNA D entered the room wearing a mask but no gloves. CNA D adjusted some items on the overbed table within 6 feet of the resident. She gathered the trash, sanitized her hands, and left the room. There was a stop sign on the door. Record review of facility's Isolation Precautions Competency dated (Revised 02/2020) read in part: .1. Document precautions (e.g., contact precautions) in the resident's medical record and care plan, for those residents requiring precautions above and beyond standard precautions. 2. b. Appropriate linen barrel/hamper and waste container, with appropriate liner, placed in or near the resident's room. Linens and waste may be appropriately bagged and removed from resident's room after delivery of care. Double-bagging of linens from isolation rooms is not necessary unless the outside of the bag is wet or visibly soiled with blood or body fluids. C. Personal Protective Equipment (PPE) maintained near or conveniently located in the resident's room, so that equipment can be accessed when needed . Record review of facility's Isolation Precautions policy dated (last revised 03/2020) read in part: .Transmission-Based precautions should be used when caring for residents requiring infection control measures above and beyond standard precautions. Document precautions (e.g., contact precautions) in the resident's medical record and care plan, for those residents requiring precautions above and beyond standard precautions. Each resident on Transmission-Based precaution should have: A STOP-See Nursing staff sign should be posted near the entrance to the resident's room to alert visitors, associates, volunteers, etc. Personal Protective Equipment (PPE) maintained near or conveniently located in the resident's room, so that equipment can be accessed when needed. Appropriate linen barrel/hamper and waste container, with appropriate liner, placed in or near the resident's room. Linens and waste may be appropriately bagged and removed from resident's room after delivery of care. Double-bagging of linens from isolation rooms is not necessary unless the outside of the bag is wet or visibly soiled with blood or body fluids. C. Personal Protective Equipment (PPE) maintained near or conveniently located in the resident's room, so that equipment can be accessed when needed. Provide the right supplies for ease-of-use and correct use of personal protective equipment. Make PPE, including facemasks, eye protection, gowns, and gloves, available immediately outside of the resident room . Record review of facility's Table 1: Accepting Hospital Admission when there are no COVID-19 cases present in the LTC facility (not dated) read in part: .3. Place in contact precaution per CDC guidance based on new strategies to optimize PPE supplies. 4. Create separate wing/unit or floor to accept patients. This may mean moving residents in facility to create a new unit/ floor. Limit staff working between units as much as possible. If COVID-19 negative they should be admitted and managed per usual care for respiratory symptoms adopting new CDC guidance for strategies to optimize PPE supplies . These failures resulted in an Immediate Jeopardy (IJ). The Administrator was notified of the IJ on 5/15/20 at 2:30 pm and a plan of removal (POR) was requested at that time. The IJ template was left with the Administrator. After two revisions, the POR was accepted on 5/18/2020 at 1:00 pm. The POR read: .5/15/20 Brookdale Galleria - Plan of Removal This plan of removal for Brookdale Galleria documents the immediate action this community will take to address the issues noted by the surveyor. Identifying those who are affected or could be affected - This practice identified could affect 34 residents in the community. There were no positive cases in the community. One resident transferred out to the hospital on [DATE] due to shortness of breath. He was subsequently tested twice at the hospital and was negative for COVID 19. The X-ray technician did not wear full PPE while obtaining a chest x-ray. The visitor screening log was checked and verified. She was identified as being both asymptomatic and afebrile. The remaining 33 residents had negative COVID 19 testing prior to admission and currently remain asymptomatic per resident COVID 19 screenings. Actions the community has taken - Newly ad (TRUNCATED)

Based on observation, interview and record review the facility failed to implement policies/procedures to ensure the necessary care and services to maintain the highest practicable and physical and mental well-being for 1 of 6 residents, (CR #3) reviewed for neglect as evidenced by: -Failure to assess the temperature, blood pressure, pain level, administer medications and chart every shift for CR # 3 who returned to the facility after an outpatient procedure on [DATE] at 3:20 pm and expired in the facility on [DATE] at 6:30 am. The failure affected one discharged resident and placed 48 current residents at risk of mental and physical decline due to delay in assessment and treatment. Complaint # 5 The findings include: CR #3 Record review of CR #3's file revealed an admission and history dated [DATE] that revealed CR#3 was a [AGE] year old male. His [DIAGNOSES REDACTED]. Record review of the facility's admits/discharge report dated [DATE] to [DATE] revealed CR #3 was transferred to a local hospital on [DATE] and returned on [DATE]. Further review revealed an additional discharge date of [DATE] due to CR #3 expired. Record review of CR #3's admission and history report revealed CR #3 came to the facility to be prepared for his possible shunt placement ( tube in brain area to enable drainage of fluid from brain into abdominal area)and subsequent coronary artery graft. Record review of CR #3's admission and history functional status was documented as ambulated with rolling walker, basic ADL's dependent, continent of bowel and bladder, mental status was alert and followed commands, dementia uncertain. Record review of the admission and history examination section revealed CR #3 was in no acute distress but quite confused, head norm cephalic and a traumatic, cardiac heart sounds were normal , heart rhythm and rate regular and no [MEDICAL CONDITION]. Vital signs: BP-,[DATE], P-79, R-18, T-98.2. Record review of the hospital discharge instructions dated [DATE] for CR # 3 included documentation to keep incision dry , take fall precautions, call the office if temperature is greater than 101.5 F , have increased redness or discharge from wound or have increased pain. Record review of the facility's admission orders [REDACTED] -[MEDICATION NAME] ,[DATE] mg 1 to 2 tablets by mouth every 4 to 6 hours as needed, -[MEDICATION NAME] (heart medication) 3.125 mg 1 capsule by mouth 2 times per day -[MEDICATION NAME] (prostate medication) 0.5 mg give 1 by mouth daily -Atorvastatin (heart medication) 80 mg tab, give 1 by mouth daily. -[MEDICATION NAME] 2% ointment apply 1 inch topically every 8 hours Record review of the facility's MAR indicated [REDACTED] -[MEDICATION NAME], 3.125 mg on [DATE] at 4:00 pm; -Blood pressure on [DATE] at 4:00 pm was blank/undocumented; -[MEDICATION NAME], 0.5 mg on [DATE] at 8:00 pm; -Atorvastatin, 80 mg at 8:00 pm; and -[MEDICATION NAME] 2% ointment at 4:00 pm. Record review of the MAR dated [DATE] to [DATE] for CR#3 revealed no documentation/orders to keep incision dry, take fall precautions, call the office if temperature is greater than 101.5 F, have increased redness or discharge from wound or have increased pain. Record review of the TAR dated [DATE] to [DATE] for CR # 3 revealed the interventions/approaches that were to be assessed on [DATE] on the 3:00 pm to 11:00 pm shift were blank/undocumented. Record review of an undated facility's daily skilled nurse's note for CR# 3 revealed the vital signs were documented in the top right corner, however the assessment section was blank/undocumented. Further review of the same nurses note form revealed an untimed entry dated [DATE] that CR #3 arrived via ambulance quiet, calm; was lying in bed, easily aroused. Charge nurse on duty entered room and said CR#3 is in pain. The Admission Nurse assured that pain medications and all assigned medications should still be on nurse's chart. Further review of the skilled nurse note for CR #3 revealed no documentation or assessment was charted by the 3:00 pm to 11:00 (evening) shift nurses. Record review of the facility's daily skilled nurse's notes for CR# 3 revealed an entry dated [DATE] at 6:05 pm that read "CR#3 who was found in his bed to be non-responsive and cool to touch. CPR was started immediately and 911 was called. CPR was preformed until EMTs arrived and pronounced CR#3 dead at 6:30 am. DON notified". The final entry for [DATE] at 10:30 am revealed CR# 3's body was picked up by Medical Examiner's office. In an interview on [DATE] at 1:50 pm with the Administrator, she stated in order to ensure care and services were provided in accordance with the plan of care, she conducted floor rounds and talked with the residents and family members. She said a daily meeting was held early each morning with all department heads to identify, review and address all concerns and problems, incidents and 24 hour reports. She said weekly quality of care meetings were held to track and review areas including weights, skin issues and falls. The Administrator said follow-up was conducted on quality of care log and records were audited. In an interview on [DATE] at 9:15 am with the ADON, she said all medications and treatments were to be transcribed from the admission orders [REDACTED]. The ADON said, " We, the DON and I, have just started to audit resident charts, to monitor and identify if all information is transcribed to Resident's records, MAR/TAR, when a resident comes to the facility " . In an interview on [DATE] at 10:45 am, the DON said if there were more than 1 or 2 admissions then she would conduct the assessments of resident and complete the paperwork. The DON said, typically the admission information is faxed from the hospital/facility to the Marketing Director who gave the clinical information to her. She further said when the clinical and admission information was approved the hospital/facility was notified and a report was received by the Admission nurse. In continued interview at that time, the DON said the Admission Nurse conducted a head to toe assessment, called the doctor about the medications and orders, completed the admission package documentation and reported to the Charge nurse. The DON was asked if the Admission nurse was the sole reviewer of the Admission documentation and she said she, the DON, reviewed the medication list and the narcotic triplicates that came from the hospital. She said she checked for additional treatments. She said the hospital discharge plan/instructions were written as a physician's orders [REDACTED]. The DON was asked where were the nurses to document a resident's blood pressure assessment taken as ordered before medication administration and she said the nurse was to document it on the MAR/TAR record of the resident at the time it was taken and not just put an initial on the MAR/TAR. The DON further said the staff was being directed to document the BP value on the resident's MAR/TAR. In an interview on [DATE] at 1:15 pm with the Admission Nurse about CR#3's return to the facility on [DATE] she said she completed the discharge orders/instructions. At that time, the Admission Nurse was shown the neurosurgery discharge instructions dated [DATE] at 2:04 pm for CR#3 and was asked why the discharge instructions were not documented on CR#3's MAR/TAR. The Admission Nurse said " you mean these discharge directions should be put in the nursing facility ' s records, the MAR/TAR, I see what you mean " . At that time, the Admission Nurse was asked if she had received education/in- service from the facility about what to do with the discharge plan/instructions provided for a resident and she said, "no, but the DON has given me some direction at times". In an interview on [DATE] at 1:45 pm with the DON, she was asked what resident discharge instructions, community or hospital transfer information was to be followed by the admitting facility and she said all the discharge instructions were to be followed. The DON said "we didn't document that we assessed this man (CR #3)". At that time, the DON was told the MAR/TAR and nurse notes had no documented assessments of CR #3 pain, temperature or blood pressures and the DON said " there should have been". Record review of the Death and Mortician's Receipt for CR #3 revealed "a [AGE] year old male who returned to facility on [DATE] at 3:20 pm and date of death was [DATE] at 6:30 am". The remarks section revealed Medical Examiner's office called, requested records to be sent to regional office, accidental versus natural death. They will be here to pick-up CR #3 shortly. The section on mortician's receipt revealed the Medical Examiner received the remains of CR#3 on [DATE] at 10:30 am. Record review of the facility's policy and procedure on abuse and neglect dated ,[DATE] read in part "... Our residents have the right to be free from abuse, neglect ... 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect..." Record review of a facility In-service dated [DATE] on Elder abuse and neglect included facility policy and procedure dated ,[DATE] on Elder abuse and neglect which read in part "... -Physical neglect involved failure to provide goods and services necessary for the health and well-being of the elder..." Record review of the facility's policy and procedure dated ,[DATE] on Bed-hold residents revealed "... 5. If resident is hospitalized and expected to return, the resident's medical records may remain open...The usual admission screening process for medical adequacy of care should be followed". Record review of the facility's policy and procedure dated ,[DATE] on Admission, Assessment and Orders revealed: Policy detail: 1. The admitting nurse should complete the Clinical Admission Check-off list. 2. The nurse who admits the resident is responsible for completing the nursing assessment and reviewing the information sent by the discharging community, hospital and/or attending physician. The following information is required for the nursing admission assessment ...physical toe to head assessment, other as indicated. 3. The admitting nurse should complete the admission note following the nursing assessment related to resident ' s clinical assessment and based on those findings... 5. The admitting nurse will contact the attending physician after the resident had been admitted to the community and assessed... b. All orders should be reviewed and verified with the physician. Record review of the facility's policy and procedure dated [DATE] on Re-admission process revealed: -The community's readmission process must be completed for readmissions... 3. The Admission check list should be used for readmissions ... Record review of the facility's Clinical checklist form dated 2011 revealed the form included "... -physician orders [REDACTED]. -orders are transcribed to MAR, treatment sheet and CNA flow sheet -hospital discharge sheet, H&P and transfer orders are filed in the chart -complete pain assessment -complete interim care plan -all new admissions should be charted on every shift for 72 hours. The CMS 672 revealed Resident census was 48.