Every finding on record at Columbus Health and Rehab

Based on observation, interview and record review, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature. This has the potential to affect 39 of 39 residents residing in the facility on 3 of 3 units. R12, R18, R7, R30, R39, R2, R42, and R17 voiced concerns to staff related to receiving hot foods at a cold and undesirable temperature. These residents reside on 3 of 3 units. Surveyor conducted a test tray, and the result was not palatable. R10, R23. R49 and R1 voiced concerns regarding cold food. Evidenced by: The facility did not provide a policy and procedure for food temperatures. Example 1 On 05/19/26 at 12:26 PM during initial screening, R10 stated the food is terrible. Everything is cold. I eat in my room and by the time I get it, it is cold. I occasionally go to the dining room, but it is still cold. Example 2 On 05/19/26 at 8:55 AM, during initial screening, R23 stated that the food was terrible. It is always cold. I guess they would heat it up but I shouldn't have to ask. You get tired of eating cold food. Example 3 On 05/19/26 at 10:03 AM during initial screening R49 stated that the food is not good. It is usually cold. The oatmeal is never warm, let alone hot. On 05/21/2026 at 8:02 AM, R49 indicated to surveyor that the oatmeal was cold yesterday. R49 went to the dining room yesterday for dinner and the biscuits were soggy. Example 4: On 5/19/26 at 10:04 AM, Surveyor interviewed R1 during initial screening. R1 indicated that food is cold when receiving meal trays in room. Example 5 On 5/19/26 at 3:50 PM, during resident council meeting R12, R18, R7, R30, and R39 indicated they receive hot foods at a cold and undesirable temperature. R12, R18, R7, R30, and R39 also indicated they have voiced concerns many times to staff regarding their food being served at undesirable temperatures. On 5/20/26 at 9:09 AM, CNA P (Certified Nursing Assistant), CNA G, and CNA O indicated R2, R7, R42, and R30 often complain about receiving their hot foods at a cold or undesirable temperature. On 5/20/26 9:04 AM Surveyor received a test tray and recorded the following temperatures and descriptions: biscuits and gravy- 98 degrees, cool to touch. scrambled eggs 96 degrees cool to touch . hot cereal 132 degrees. Surveyor noted the metal disc under the plate and the plate to be lukewarm to the touch. On 5/20/26 at 2:24 PM, AD S (Activity Director) indicated R7 complains almost daily that her hot meals are served at a cooler and undesirable temperature. On 5/21/26 at 12:14 PM, DM M (Dietary Manager) indicated 96 degrees, and 98 degrees are not desirable temperatures for hot food. DM M indicated he is aware there have been concerns related to cold food. DM M indicated staff were supposed to serve one hallway at a time, but yesterday they put all three hallways on one insulated cart and passed them out. DM M indicated the meals cool down fast because the cart door opens and closes for each tray to be passed. On 5/21/26 at 2:11 PM, NHA A (Nursing Home Administrator) indicated hot foods should be served hot and cold foods should be served cold. NHA A indicated the facility has a Project Improvement Plan for meal temperatures, but the kitchen staff failed to follow the plan and resorted back to old ways where they put all room trays in an insulated cart and took them all out at once. NHA A indicated the plan is to serve one hallway and pass those. Then return to the kitchen to serve up the next hallway and pass those. Then return for the third hallway's trays and pass. This was an effort to not have to have the trays in the insulated cart cooling while waiting to be passed.

Based on observation, interview, and record review, the facility did not maintain a safe and sanitary environment in which food is prepared, stored, and distributed. This has the potential to affect all 39 residents who reside in the facility.Surveyor observed 3 sprinklers and the surrounding ceiling to be covered in a layer of dust. The sprinklers are directly above food preparation area.Surveyor observed the facility's freezer to have frozen drips hanging from the ceiling and boxes that have ice buildup on and inside with food no longer sealed by the manufacturer.Surveyor observed [NAME] D serving food 2 days without donning a beard net.Surveyor observed 3 dented cans in circulation.Evidenced by:Example 1Facility policy, titled Sanitation, revised 10/22, includes: Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime.On 5/20/26 at 9:44 AM Surveyor, [NAME] N and DM M (Dietary Manager) observed 3 sprinkler heads and the surrounding ceiling to be covered in a thin layer of dust. [NAME] N and DM M indicated they were unsure who was to be cleaning these. DM M indicated there is potential for the dust to dislodge and fall into food being prepared underneath them.On 5/21/26 at 2:11 PM NHA A (Nursing Home Administrator) indicated the Maintenance staff should be cleaning these areas regularly.Example 2On 5/19/26 at 8:41 AM during the initial tour of the facility's main kitchen, Surveyor observed frozen dripping in the walk-in freezer on the ceiling, on sprinkler heads, under the shelving, and on boxes of unsealed food. DM M opened the boxes of biscuit dough, vegetables, pork fritters, and beef patties revealing they were no longer sealed by the manufacturer. DM M indicated the dripping could get inside of the unsealed packaging contaminating the food.On 5/21/26 at 2:11 PM NHA A indicated there should be some kind of barrier to protect the boxes from the dripping condensation in the freezer unit.Example 3Facility policy, titled Preventing Foodborne illness- Employee Hygiene and Sanitary Practices, last revises 10/23, includes: Hairnets and/or chef's caps, and/or beard restraints must be worn when cooking, preparing, or assembling food to keep hair from contacting exposed food, clean equipment, utensils, and linens.On 5/19/26 at 8:41 AM Surveyor observed [NAME] D to have a full goatee and to be plating residents' food without donning a beard restraint.On 5/20/26 at 12:00 PM Surveyor observed [NAME] D to have a full goatee and to be plating resident food without donning a beard restraint.On 5/21/26 at 12:14 PM DM M indicated [NAME] D should have a beard net on to cover facial hair when working with or near food.On 5/21/26 at 2:11 PM NHA A indicated all hair must be covered while working in the food preparation area.Example 4Facility policy, titled Food Safety Requirements, revised 10/22, includes: Dented cans will be identified and removed from regular dry food storage. The dented cans should be placed in a specific labeled area of the storage room awaiting pick up from the appropriate vendor.On 5/19/26 at 8:41 AM during initial tour of the facility's kitchen, Surveyor observed 3 dented cans on the shelf in the dry storage unit. During an interview, DM M (Dietary Manager) indicated he would use the dented can if it was dented as long as it was not dented on the can's seam.On 5/21/26 at 2:11 PM NHA A (Nursing Home Administrator) indicated staff should not use dented cans at all.

Based on interview and record review the facility did not ensure prompt resolution of all grievances for 3 of 3 sampled residents (R2, R7, R17) and 2 of 2 supplemental residents (R42, R30) reviewed for grievances. R2, R7, R42, R30, and R17 voiced concerns/grievances to staff. Staff did not follow the facility's grievance process. CNA P (Certified Nursing Assistant), CNA O, and CNA G indicated R2, R7, R42, and R30 voiced concerns related to being served hot food at a cool and undesirable temperature and they did not use the facility's grievance process to track, address, or look for trends throughout the facility. AD S (Activity Director) indicated R7 tells her almost daily that her hot foods are served cold and at an undesirable temperature. Evidenced by: Facility policy, titled Filing Grievances/Complaints, revised 11/2017, includes: Any resident, his or her representative, family member, or appointed advocate may file a grievance or complaint concerning treatment, medical care, behavior of other residents, staff members, theft of property, etc without fear of threat or reprisal in any form. Grievances/Complaints may be submitted orally or in writing. Upon receipt of a grievance or complaint the Grievance Official will investigate the allegations and submit a written report of such findings to the Administrator within 5 working days of receiving the grievance and/or complaint. The Grievance Official will also give written grievance decision to the resident. The community will maintain 3 years of results of the Grievance Process. The log and results will be maintained for 3 years. The Grievance/Complaint log will be reviewed by the Quality Assurance and Assessment Committee at least quarterly. Example 1: On 5/19/26 at 3:50 PM, R30 indicated she does not go to staff with concerns anymore because they do not do anything about it. R30 indicated one of her concerns is that she gets served her hot food at a cool and undesirable temperature. On 5/19/26 at 3:50 PM R7 indicated she complains to staff almost daily that her hot food being served at a cool and undesirable temperature. On 5/20/26 at 9:09 AM, CNA P, CNA O, and CNA G indicated R2, R7, R42, and R30 often complain about receiving their hot foods at a cold or undesirable temperature. CNA P, CNA O, and CNA G indicated they did not fill out a grievance form when R2, R7, R42, and R30 complained of being served cold food. CNA G, CNA O, and CNA P indicated they did not report these concerns to the facility's Grievance Official. On 5/20/26 at 2:24 PM, AD S (Activity Director) indicated R7 complains almost daily that her hot meals are served at a cooler and undesirable temperature. AD S indicated she does not record this concern on a grievance form, but she should so the facility can see how often it is occurring and try to get to the root of the concern. On 5/20/26 at 2:58 PM, NHA A (Nursing Home Administrator) indicated it is important that staff use the facility's grievance process to report grievances voiced by the residents to the facility can track and trend the grievances. NHA A indicated once a grievance is voiced the facility will investigate it and try to come up with a resolution that satisfies the person who voiced the concern. NHA A indicated a concern related to a resident's stay, the food, the care, or the environment is a grievance. On 5/21/26 at 12:14 PM DM M (Dietary Manager) indicated he is aware there have been resident concerns related to cold food and staff should be recording the concerns using the grievance forms so he can see which halls and which meals and how frequently the concerns are coming up. Example 2 R17 admitted to the facility on [DATE] and has diagnoses that include: cervical disc disorder with myelopathy, mid-cervical region (a progressive condition where a degenerated or herniated disc in the neck compresses the spinal cord, leading to loss of coordination, balance issues, and muscle weakness); Need for Assistance with personal care; muscle weakness; lack of coordination. R17's MDS (Minimum Data Set), dated 2/18/26, indicates a BIMS (Brief Interview for Mental Status) score of 15, indicating R17 is cognitively intact. On 5/19/26 at 10?32 AM, Surveyor interviewed R17 during initial screening. R17 stated that on 5/16/26 he/she had requested to use the bathroom at 11:45 AM. The nurse stated he/she would get someone. Two CNAs (Certified Nursing Assistant) came into the room separately while I was waiting, but didn't help me. Two other CNAs came in at 1:00 PM and assisted. R17 verbalized concern with needing to wait so long for assistance. R17 stated I told CNA K about the wait; he/she scolded the staff. R17 stated that the following day, one of the CNAs that didn't help me on Saturday, CNA L came to get me dressed. CNA L got me half dressed, then left without telling me where he/she was going and never came back. I waited over an hour for others to come and get me out of bed. Important to note: Surveyor reviewed facility grievance log. There was no grievance for R17 regarding concern of care. R17's Care Plan states, in part: Focus: R17 has an ADL (activities of daily living) self care deficit related to impaired balance, limited mobility, weakness. Interventions: .Transfer: May transfer with E-Z stand (mechanical transfer device) and assist of 1 except needs to use hoyer for out of bed transfers only. On 5/20/26 at 1:40 PM, Surveyor interviewed CNA J about mechanical lift transfers. CNA J stated that two staff members are needed for a hoyer transfer and one is needed for a stand, but I prefer two. Surveyor asked if CNA J is able to find assistance for transfers. CNA J stated yes, you walkie (walkie talkie) for them to come, or peek your head out of the room. Nurses will assist too. Surveyor asked how long it might take to get assist. CNA J stated it is usually quick; less than 5 minutes. Surveyor asked CNA J if R17 needs to wait for assist with transfers. CNA J stated there is usually no concern with wait time, but I have told R17 that it would be about 5 minutes before being able to get him/her up. If I move on to another resident, I always let them know that I'll be back and I or another staff goes in to do the transfer. On 5/21/26 at 7:47 AM, Surveyor interviewed CNA G and asked if R17 had concerns with waiting for assistance. CNA G stated R17 has concerns with specific people because they don't take his/her needs seriously; to put R17 to bed or take R17 to the toilet when he/she wants to. Surveyor asked how CNA G knows that R17 has a concern. CNA G stated when you go in R17s room you know if he/she had trouble because he/she won't talk; when you ask he/she opens up about the concerns. Then I talk to the nurse. On 5/21/26 at 8:27 AM, Surveyor interviewed CNA K who stated there was an incident this past weekend; I deescalated and made it better. I was in the dining room and my coworker told me that R17 needed to use the bathroom. Another situation arose, which I took care of. When I got to R17, I found out that the person who had gotten him dressed had just left him/her. R17 said the CNA came and washed me and got my shift in, then left. R17 was cussing and not liking her. During this situation, R17's light was on, one CNA was passing water and another CNA was passing trays; both told R17 they would let someone know. CNA J learned of the situation and confronted those CNAs; they admitted they didn't help R17. I let the nurses know. RN H (Registered Nurse) was here; I let him/her know. If a resident has a concern, I'd always tell DON B (Director of Nursing) or RN H. On 5/21/26 at 9:08 AM, CNA K clarified that there were 2 situations; R17 being left alone after getting half dressed was on Sunday and the 2 CNAs not answering R17's call light was on Saturday. CNA K stated it was the incident on Saturday that had been reported to RN H. On 5/21/26 at 8:42 AM, Surveyor interviewed RN H and asked what is done when a CNA reports that a resident has a concern in care. RN H stated call DON B and NHA A (Nursing Home Administrator), talk to the resident and start the grievance process. Surveyor asked about R17's concern from Saturday 5/16/26. RN H stated one person said that R17 was frustrated with one of the CNAs; someone was passing water and didn't ask when he/she needed. I did tell NHA A and DON B. I texted DON B and said that I was writing the CNA up. Surveyor asked if RN H spoke with R17. RN H stated no, it had already been dealt with and I was dealing with other things. On 5/21/26 at 8:55 AM, Surveyor interviewed CNA J who stated that on Saturday, 5/16/26, R17 had his light and that people had stopped and said they would get help, but they didn't get any help. CNA K and I saw his light on, he was very frustrated. R17 said that someone had passed his breakfast tray and another person had passed iced water, but neither told that help was needed. R17 said his/her light had been on for quite a while. He/she needed to use the bathroom, they say his/her light and didn't help. I couldn't understand why he/she was made to wait as he/she is an EZ stand transfer with one assist once up and he/she was in the chair. Surveyor asked what is done when a resident has a concern/complaint. CNA J stated get the info, apologize, and report to management. CNA K spoke with management. R17 was very upset; he/she was yelling/cussing. On 5/21/26 at 9:57 AM, Surveyor interviewed DON B and asked if a resident is upset due to needing to use the bathroom, and having staff stop in room without assisting, would this be considered a grievance. DON B stated yes, definitely. Surveyor asked if DON B was aware of R17 concerns. DON B stated no; would've expected to be updated and would've expected RN H to have spoken with R17. I would expect this to be followed through as a grievance. On 5/21/26 at 10:23 AM, Surveyor interviewed NHA A and asked if a resident is upset with care/perceived lack of care, is this a grievance. NHA A stated yes, it could potentially be neglect; we'd need to interview to rule out. Surveyor and NHA A discussed R17's voiced concerns. NHA A stated, I should have been notified.

Based on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 8 errors out of 29 opportunities that affected 3 out of 4 residents (R41, R21 & R33) included in the medication pass task, which resulted in an error rate of 27.59%.Staff administered R41's lisinopril and hydralazine at 9:15AM. R1's order is to administer at 8:00AM. Staff administered these medications late.Staff administered R21's acetaminophen and senna at 8:58AM. The order is to administer acetaminophen and senna at 7:30AM. Staff administered R21's gabapentin at 8:58AM. The order is to administer gabapentin at 7:00AM. Staff administered these medications late.Staff administered R33's carbidopa-levodopa and dabigatran etexilate at 9:22AM, metoprolol at 9:33AM, and oxybutynin at 9:23AM. These medications are ordered to be administered at 8:00AM. Staff administered these medications late. Staff administered R33 Magnesium 200mg at 9:24AM. R33's order is for Magnesium Gluconate 500mg. R33 received wrong medication and dose. Evidenced by:The facility policy entitled, Medication Administration Schedule, dated 11/2025, states, in part: . Policy Statement: Medications shall be administered according to established schedules.Policy Interpretation and Implementation:1. Medications are administered according to community protocol.3. A physician's order for specific times supersedes any routine schedule.The facility policy entitled, Medication Administration through Certain Routes, dated 6/2025, states, in part: . Applicability: . It ensures that medications are administered according to best practices, physician orders, and in compliance with current practice guidelines, and state and federal regulations. Example 1:R41 was admitted to the facility on [DATE] and has diagnoses that include hypertension (high blood pressure) and dementia (decline in cognitive abilities such as memory, reasoning and language).R41's Comprehensive Minimum Data Set (MDS) Assessment, dated 6/23/25 shows R41 has a Brief Interview of Mental Status (BIMS) score of 5 indicating R41 has severe cognitive impairment. R41's Physician Orders, dated 5/20/26, states, in part: . Lisinopril 20 mg (milligrams). Give 20 mg by mouth two times a day for hypertension. Start Date: 10/20/25.Hydralazine HCI (hydrochloride) 50 mg. Give 50 mg by mouth three times a day for hypertension. Start Date: 2/19/26. R41's MAR (medication administration record) states, in part: . Lisinopril (a medication to treat high blood pressure) 20 mg: Give 20 mg by mouth two times a day for hypertension. Start Date: 10/20/25. at 8:00AM & 8:00PM.Hydralazine HCI 50 mg. Give 50 mg by mouth three times a day for hypertension. Start Date: 2/19/26. at 8:00AM, 12:00PM & 5:00PM. R41's Administration History Report, dated 5/19/26 shows:-Hydralazine HCI 50 mg was administered on 5/19/26 at 9:15AM-Lisinopril 20 mg was administered on 5/19/26 at 9:15AM. On 5/19/26, at 9:15AM Surveyor observed RN C (Registered Nurse) administer R41's hydralazine and lisinopril.Note: These medications are ordered to be administered at 8:00AM. Example 2:R21 was admitted to the facility on [DATE] and has diagnoses that include constipation and pain.R21's Quarterly Minimum Data Set (MDS) Assessment, dated 12/26/25 shows R21 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R21 is cognitively intact.R21's Physician Orders, dated 5/20/26, states, in part: . Acetaminophen 325mg. Give 2 tablets orally two times a day for pain. Start Date: 4/30/26.Gabapentin 300mg. Give 1 capsule by mouth three times a day for pain. Start Date: 12/26/25.Senna S 8.6-50mg (Sennosides-Docusate Sodium). Give 2 tablets orally two times a day for constipation. R21's MAR (medication administration record) states, in part: . Acetaminophen Oral Tablet 325 mg. Give 2 tablets orally two times a day for pain. at 7:30AM & 4:00PM.Senna S Oral Tablet 8.6-50 mg (Sennosides-Docusate Sodium). Give 2 tablets orally two times a day for constipation. at 7:30AM & 4:00PM.Gabapentin Capsule 300mg. Give 1 capsule by mouth three times a day for pain. at 7:00AM, 12:00PM & 4:00PM. R21's Administration History Report, dated 5/19/26 shows:-Acetaminophen 650mg was administered on 5/19/26 at 8:58AM-Gabapentin 300mg was administered on 5/19/26 at 8:58AM-Senna S 8.6-50mg (2 tablets) was administered on 5/19/26 at 8:59AM On 5/19/26, at 8:59AM, Surveyor observed RN C administer R21's acetaminophen, gabapentin and senna s.Note: Gabapentin is ordered to be administered at 7:00AM. Acetaminophen and Senna S are ordered to be administered at 7:30AM. Example 3:R33 was admitted to the facility on [DATE] and has diagnoses that include hypertension (high blood pressure), history of venous thrombosis (a blood clot in a deep vein) and embolism (clot that breaks loose and travels to the lungs), and chronic pain syndrome. R21's Comprehensive Minimum Data Set (MDS) Assessment, dated 5/6/26 shows R21 has a Brief Interview of Mental Status (BIMS) score of 15 indicating R21 is cognitively intact.R21's Physician Orders, dated 5/20/26, states, in part: . Carbidopa-Levodopa Oral Tablet 25-100 mg. Give 1.5 tablets by mouth two times a day. Start Date: 5/16/26.Dabigatran Etexilate Mesylate Oral Capsule 150mg. Give 1 capsule by mouth two times a day for DVT (Deep Vein Thrombosis) prophylaxis. Start Date: 5/06/26.Metoprolol Tartrate Oral Tablet 25 mg. Give 1 tablet by mouth two times a day for hypertension. Start Date: 5/06/26.Oxybutynin Chloride Oral Tablet 5mg. Give 1 tablet by mouth two times a day for overactive bladder. Start Date: 5/09/26.Magnesium Gluconate Oral Tablet 500mg. Give 1 tablet by mouth one time a day for supplement. Start Date: 5/10/26. R33's MAR (medication administration record) states, in part: . Magnesium Gluconate Oral Tablet 500 mg. Give 1 tablet by mouth one time a day for supplement. Start Date: 5/07/26. at 6:00AM-10:00AM.Carbidopa-Levodopa Oral Tablet 25-100mg. Give 1.5 tablets by mouth two times a day. Start Date: 5/16/26. at 8:00AM & 2:00PM.Dabigatran Etexilate Mesylate Oral Capsule 150mg. Give 1 capsule by mouth two times a day for DVT prophylaxis. Start Date: 5/06/26. at 8:00AM & 8:00PM.Metoprolol Tartrate Oral Tablet 25mg. Give 1 tablet by mouth two times a day for hypertension. Start Date: 5/06/26. at 8:00AM & 8:00PM.Oxybutynin Chloride Oral Tablet 5mg. Give 1 tablet by mouth two times a day for overactive bladder. Start Date: 5/09/26. at 8:00AM & 8:00PM R33's Administration History Report, dated 5/19/26 shows:-Carbidopa-Levodopa was administered on 5/19/26 at 9:22AM-Dabigatran Etexilate Mesylate was administered on 5/19/26 at 9:22AM-Metoprolol Tartrate was administered on 5/19/26 at 9:33AM-Oxybutynin chloride was administered on 5/19/26 at 9:23AM-Magnesium Gluconate 500mg was administered on 5/19/26 at 9:24AM On 5/19/26 at 9:33AM, Surveyor observed RN C administer magnesium 200mg, oxybutynin, metoprolol, dabigatran etexilate, and carbidopa-levodopa to R33. Note: The order is for magnesium gluconate 500mg. The order is for oxybutynin, metoprolol, dabigatran etexilate, and carbidopa-levodopa to be administered at 8:00 AM. On 5/19/26 at 2:15PM, DON B (Director of Nursing) indicated medications ordered at a specific time such as 8:00AM means the medication can be administered an hour before 8:00AM up to an hour after 8:00AM. Medications ordered 6:00AM-10:00AM must be administered during that time.On 5/20/26 at 8:56AM, Surveyor interviewed DON B and reviewed the medication administration history report for R41, R21, and R33 for 5/19/26 morning medication pass. DON B indicated she would expect medications ordered at 8:00AM to be administered by 9:00AM and medications ordered for 7:30AM to be administered by 8:30AM. Medications ordered from 6:00AM-10:00AM should be administered within that time. Medications on the MAR for a specific time should be administered an hour after the scheduled time. DON B agreed R21, R41, and R33 medications administered late were medication errors. DON B indicated the magnesium 200mg administered to R33 was the wrong medication and dose. R33's medication order is for magnesium gluconate 500mg. DON B indicated this is a medication error. On 5/20/26, at 9:10AM, Surveyor interviewed RN C. Surveyor asked for medications ordered at a specific time when should the medications be administered. RN C indicated an hour before the scheduled time up to an hour after the scheduled time. RN C indicated for medications scheduled to be administered 6:00AM-10:00AM must be administered during that time. Surveyor reviewed the times R21, R41, and R33 received their medications on 5/19/26. RN C indicated R21, R33, and R41's medications were administered late on 5/19/26 for the morning medication pass. Surveyor asked if medications administered late would be a medication error and RN C indicated it would not be classified as an error but late. Surveyor asked RN C what R33's order for magnesium is. RN C looked at the orders and indicated magnesium gluconate 500mg. Surveyor brought to RN C's attention that magnesium 200mg was administered on 5/19/26. RN C pulled out R33's bottle of magnesium and verified it was the wrong medication and dose. RN C indicated she would notify the physician to get the order changed as R33's magnesium was brought from home.

Based on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 8 staff reviewed for background checks.CK D (cook) was hired by the facility on 3/18/26. CK D's Background Information Disclosure (BID) Form, dated 3/18/26, indicated he lived in Iowa and [NAME] Virginia in the last three years. The facility did not do a background check for Iowa or [NAME] Virginia.Evidenced by:The facility policy entitled, F606, F607 Abuse Prevention Program, Screening of Employees, dated 10/25, states, in part: . Policy: The community will not employ or otherwise engage individuals whom have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law, entered into the State nurse aide registry or against the professional license they hold with the state licensure body.Guidelines:1. Background checks are completed per state guidelines on each employee.2. Pre-employment screening will consist at a minimum: a. Employment history b. Information from former employers as available, andc. Documentation of status and any disciplinary actions from licensing or registration boards or registries.9. Regardless of the source of the check, maintain the document that the screening occurred.CK D (cook) was hired by the facility on 3/18/26. CK D's Background Information Disclosure (BID) Form, dated 3/18/26, indicated he lived in Iowa and [NAME] Virginia in the last three years. The facility did not do a background check for Iowa or [NAME] Virginia.On 5/20/26, at 10:38AM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor reviewed CK D's BID that indicated CK D had lived in Iowa and [NAME] Virginia in the past three years. Surveyor asked NHA A if CK D had a background check for Iowa and [NAME] Virginia. NHA A looked through CK D's file and could not see one. NHA A reached out to business office manager, who was out on medical leave. NHA A returned to Surveyor and indicated the background checks for Iowa and [NAME] Virginia had been missed and should have been completed. NHA A indicated she had filed for the background check, and it is pending at this time. Surveyor informed NHA A there was a concern for the background checks not being completed.

Based on interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (R24) reviewed for elopement.The facility did not accurately assess R24's risk for elopement, did not update R24's care plan with personalized interventions when Interdisciplinary team came up with interventions to prevent elopements, and did not follow care planned interventions of increased supervision. R24 was found to be outside ambulating independently.Evidenced by:The facility did not provide a policy related to Elopement.R24 admitted to the facility on [DATE] with diagnoses including dementia.R24's Hospital Discharge Note, dated 10/24/25, includes: . Reason for admission and hospital course: The patient . who comes to . hospital with increasing confusion. She had been wandering outside of her house. She was brought in to emergency room.R24's Elopement Risk Assessment, dated 10/24/25, includes: New Admission. BIMS (Brief Interview for Mental Status) available: no. Orientation: person. The resident is non-ambulatory: No. Resident exhibits forgetfulness or shortened attention span and is independently mobile: unchecked. Wandering/Exit Seeking Patterns: Check all that apply- History of wandering at home or other setting, including current setting, with or without purpose- checked, history of exit seeking at home or other setting, including current setting- unchecked. Factors: check all that apply- new roommate last 30 days? (blank). New room last 30 days, including move to another unit: (blank). Recent admission past 30 days- checked. Verbalizes hallucinations last 30 days- unchecked. Current evaluation: lacks safety awareness of current situation- checked. Diagnoses: Dementia- unchecked. Alzheimer's unchecked. Score: 8 low risk.(It is important to note the risk assessment does not reflect R24's moments of forgetfulness, diagnosis of dementia, or history of exit seeking. R24 scored low as an elopement risk, but this was why she went to the hospital to begin with.)R24's Social Services Note, dated 10/27/25, includes, in part: . She is alert and oriented times 2.R24's Comprehensive Care Plan, updated on 10/28/25 to include: R24 has a potential for an elopement/wandering due to poor safety awareness, history of wandering and cognitive deficits.Goal- R24 will remain safe within the designated confines of the community. Interventions- Encourage as much participation in activities that the resident can endure or comprehend. Give clear explanations of all care to be provided. Increase R24's supervision by the staff during increased exit seeking or unsafe wandering.R24's Nurse Note, dated 11/19/25, includes: . Exit seeking behavior first half of shift. Needed one on one supervision for safety. Daughter called per resident request and daughter came in briefly around supper to visit resident and was updated on resident's behavior.R24's Interdisciplinary Team Note, dated 11/21/25, includes: . Resident exhibiting exit seeking behaviors in the evening this week. Resident reports that she needs to get home and believes her house is just down or across the street. Wanderguard in place and staff ensure proper placement and functioning every shift. Resident is able to be redirected away from exits. Plan- Staff continue to offer diversional activities and redirection away from exits during periods of exit seeking. Resident provided reassurance during these times that she is in facility receiving therapy at this time and that family knows she is here. Daughters called on phone at times to also reassure resident that they know she is here and safe in the facility.(It is important to note the interventions mentioned in the Plan by the Interdisciplinary Team of providing reassurance to R24 by voicing to her that she is at the facility to receive therapy and her family knows she is here. Also important to note these interventions are not added or included in R24's Comprehensive Care Plan.)R24's Elopement Risk Assessment, dated 12/9/25, includes: BIMS available: yes. BIMS score: (blank). Resident exhibits forgetfulness or shortened attention span and is independently mobile: unchecked. Wandering/Exit Seeking Patterns: check all that apply- history of wandering at home or other setting with or without purpose- checked, history of exit seeking at home or other setting, including current setting- unchecked, stays near exit doors- unchecked, wanders after dark/sundowns- unchecked, talks about leaving, expresses desires to leave- unchecked.(It is important to note that the following are not checked on R24's Elopement Risk Assessment: stays near exit doors, history of exit seeking at home or other setting. Including current setting, wanders after dark/sundowns, talks about leaving, expresses desires to leave while Nurse Notes indicate R24 is having exit seeking behaviors around supper/possibly sundowning, resident able to be redirected from exits during periods of exit seeking.)R24's Nurse Note, dated 1/26/26, includes: . at 1915, alarm sounded at back door of end of . hallway. Staff ran down to door and noted R24 was right outside back door and was ambulating. Chair was inside building in hallway. Staff assisted R24 back into building and into wheelchair. Was wearing sweatshirt, pants, and gripper socks at time of incident. No further attempts. Wander guard in place on wrist and functioning properly.(It is important to note R24 was independently mobile and had eloped/walked out the door of the building.)R24's Nurse Note, dated 1/27/26, includes: . Note Text: Report from previous shift that R24 attempted to elope the facility through a side door with no coat or shoes on. Staff have been attempting to redirect her all night. R24 has come out of her room multiple times roaming. While staff were away from the nursing station, R24 attempted to go through the front door. Staff redirected her and put her into bed. Night shift has been doing 30 minute checks for safety.R24's Interdisciplinary Team Note, dated 1/27/26, includes: Resident had a noted elopement attempt on 1/26/26. Following supper meal, resident noted to be more confused thinking family or friends were coming to pick her up. Resident redirected by staff. At approximately 1915, staff heard the 300 wing emergency exit doors alarm and responded immediately. Resident was noted to have left wheelchair at the end of the hallway near the emergency exit door and was ambulating through the emergency exit doors. Staff member was able to immediately redirect her back inside and into wheelchair. Plan : Resident continues to have functioning wandergard in place due to known elopement risk. Contributing factors to increase in behaviors identified as recent COVID infection with newly discontinued isolation precautions that may result in need for reorientation to facility secondary to dementia.(It is important to note R24 was noted to be more confused and required staff redirection, but staff only heard the emergency exit door alarm and had not increased R24's supervision per R24's care plan and R24 was found outside ambulating independently.)R24's Elopement Risk Assessment, dated 1/27/26, indicates R24 is a low risk for elopement with a score of 4. The assessment includes: . Is BIMS available- No . BIMS score (blank) . Wandering/exit Seeking Patterns: Check all that apply. Resident exhibits forgetfulness or shortened attention span and is independently mobile- unchecked. History of wandering at home or other setting, including current setting, with or without purpose- unchecked . History of exit seeking at home or other setting, including current setting- unchecked . Stays near exit doors- unchecked . Wanders after dark/sundowns- unchecked. Talks about leaving- unchecked . Lacks safety awareness of current situation- unchecked . Current state of agitation or restlessness- unchecked . (It is important to note R24 had an actual elopement/got outside of the building and her score is now lower indicating she is less of a risk for elopement then before she eloped. It is important to note R24's elopement risk assessment is inaccurate and incomplete.)R24's Comprehensive Care Plan, updated on 1/27/26, to include: Do one on one with (R24) if agitated.R24's Nurse Note, dated 1/30/26, includes: Resident with noted increase in restlessness, agitation, and exit seeking earlier this week. Staff provided increased supervision and redirected resident to ensure safety during episodes of exit seeking. Resident behaviors much improved at the end of the week with no current exit seeking behaviors noted at this time. Staff continue to assist resident with redirection during behavioral episodes.R24's Elopement Risk Assessment, dated 2/16/26 indicates R24 is a moderate risk for elopement with a score of 13.R24's Comprehensive Care Plan, updated 2/16/26, to include: Assess for pain, hunger, thirst or toileting needs with increase restlessness. R24's Interdisciplinary Team Note, dated 2/20/26, includes: Resident was noted to have an increase in behaviors and impaired mood yesterday. Resident exhibiting wandering and exit seeking and was noted to be irritable with staff and family. Resident was able to be redirected during wandering/exit seeking episodes. New order Seroquel 12.5mg (milligrams) every 8 hours as needed for agitation for 14 days. She had been exhibiting exit seeking behaviors, experienced increased restlessness, and agitation.R24's Elopement Risk Assessment, dated 4/13/26, includes: . Orientation- person. BIMS available- yes. BIMS- (blank). Wandering/Exit Seeking Patterns- check all that apply. History of wandering at home or other setting, with or without purpose- checked, history of exit seeking at home or other setting, including current setting- checked, packs belongings to go home- unchecked, stays near exit doors- unchecked, wanders after dark/sundowns- unchecked, talks about leaving, expresses desires to leave- checked. Verbalizes hallucinations in the last 90 days- unchecked. Current Evaluation- lacks safety awareness- checked. Current state of agitation of restlessness- unchecked. Diagnoses- dementia- checked. Current Medications: none checked. Score- 9 low risk.(It is important to note this assessment does not reflect R24's behaviors of staying near exit doors, having moments of restlessness, and is incomplete as R24's BIMS scores are not included.)R24's Nurse Note, dated 5/13/26, includes: Resident has been quite restless this AM shift. Resident up early and took medications, noted to self transfer to wheelchair and attempt to make a phone call from a phone in the hallway. Resident assisted to sit back down but then proceeded to wander the halls in her wheelchair, attempting to exit at each door she found. Staff able to intervene and redirect.On 5/21/26 at 8:50 AM DON B (Director of Nursing) indicated assessments should be complete and accurate. DON B indicated R24's elopement risk assessments were not complete or accurate. DON B indicated R24's care plan should be updated timely and include personalized/individual interventions that the Interdisciplinary Team comes up with.On 5/21/26 at 1:29 PM NHA A (Nursing Home Administrator) indicated assessments should be complete and accurate. NHA A indicated R24's care plan should have been updated with interventions discussed by the Interdisciplinary Team. NHA A indicated R24's elopement risk assessments are not accurate and are not complete.

Based on interview and record review, the facility did not investigate an alleged violation of neglect for 1 of 14 residents (R17) reviewed for abuse.R17 reported to CNA G that R17 hadn't been changed/cared for all night. The facility did not complete an investigation.Evidenced by:The facility's F607 Abuse Prevention Program, Investigation F600, F602, F603, F610, dated 10/25, states, in part: Reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management.1. Should an incident or suspected incident of resident abuse, mistreatment, misappropriation, neglect or injury of unknown source be reported, the Administrator, or his/her designee, will appoint a member of management to investigate the alleged incident.R17 admitted to the facility on [DATE] and has diagnoses that include: cervical disc disorder with myelopathy, mid-cervical region (a progressive condition where a degenerated or herniated disc in the neck compresses the spinal cord, leading to loss of coordination, balance issues, and muscle weakness); Need for Assistance with personal care; muscle weakness; lack of coordination.R17's MDS (Minimum Data Set), dated 2/18/26, indicates a BIMS (Brief Interview for Mental Status) score of 15, indicating R17 is cognitively intact.On 5/21/26 at 7:47 AM, Surveyor interviewed CNA G (Certified Nursing Assistant) regarding R17. CNA G stated that a couple of weeks ago, R17 stated that he/she had not been changed all night. CNA G stated he/she told DON B (Director of Nursing) and RN H (Registered Nurse).On 5/21/26 at 7:57 AM, Surveyor interviewed LPN I (Licensed Practical Nurse) and asked what is done if a resident says no one has helped them all night. LPN I stated ask the CNA what they noticed, is the resident soiled. Look for documentation. Talk to the resident, take care of their need. Talk to the staff the next night. Surveyor asked if anyone else is talked to. LPN I stated he/she would speak with DON B. Surveyor asked about R17. LPN I stated there was one morning where R17 claimed he/she wasn't cared for; when I spoke with the CNA it sounded like a refusal. I don't think I was the nurse on that hall, I think I had stopped to assist. The resident told the CNA and myself. I shared with the nurse, so I felt it was handled.On 5/21/26 at 8:42 AM, Surveyor interviewed RN H and asked what is done if a CNA reports that a resident has a concern with their care. RN H stated call the DON (Director of Nursing) and NHA (Nursing Home Administrator), talk to the resident, and start the grievance process. Surveyor asked about R17 voicing concern of not being changed all night. RN H stated not that I know of. Surveyor asked what would happen if this was reported. RN H stated I'd talk to the resident and tell DON B and NHA A (Nursing Home Administrator).On 5/21/26 at 9:37 AM, Surveyor interviewed R17 and asked if there had been a concern of not being cared for during the night. R17 stated yes, the CNAs shift was from 10:00 PM to 6:00 AM; usually they will come in about 3-4 times during the night; he/she had come in around 11:00 PM and asked if I was dry, I said yes, and he/she left. He/she didn't talk with me the rest of the night. He/she came back in at 5:00 AM, when the shift was almost over. He/she should've checked on me, I need to be changed a couple of times during the night, but he/she didn't check. Surveyor asked if R17 told anyone. R17 stated yes, I tell whoever is on duty.On 5/21/26 at 9:57 AM, Surveyor interviewed DON B and asked if it is a potential allegation of neglect if a resident says they didn't get changed all night. DON B stated yes, we'd need to investigate and report. Surveyor asked if it had been reported to DON B that R17 stated that a couple weeks ago R17 hadn't been changed all night. DON B stated, not that I am aware of.On 5/21/26 at 10:23 AM, Surveyor interviewed NHA A and asked if it is a potential allegation of neglect if a resident says they didn't get changed all night. NHA A stated yes, would need to self report the allegation of neglect, protect the resident through investigation of the alleged perpetrator, remove that person from the building/suspend pending investigation, interview other staff and residents. Surveyor asked if R17's concern was reported. NHA A stated no, I didn't know about this until now; it should've been reported. I will start the investigation and submit a report.

Based on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 14 Residents (R17) reviewed for abuse.R17 reported an allegation of neglect and the facility did not submit a report to the State Agency (SA).Evidenced by:The facility's F609, Reporting of Abuse Allegation policy, dated 10/25, states, in part: All suspected violations and all substantiated incidents of abuse, neglect, exploitation or mistreatment, including injuries of unknown sources and misappropriation will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law.Definitions: Alleged violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor, another rhealth care provider, or others but has not yet been investigated and, if verifited, could be noncompliance with the Federatl requirements related to mistreatment, exploitation, neglect, abuse, including injuries of unknown source, and misappropriation of resident property. Guidelines .2. Should a suspected vilation or a reasonable suspicion or substantiated incident of mistreatement, neglect, injuries of an unknown source, or abuse be reported, the facility administrator, or his/her designee in their absence, will promptly notify the following persons or agencies (verbally and written) of such incident: a. The State licensing/certification agency responsible for surveying/licensing the facility; .R17 admitted to the facility on [DATE] and has diagnoses that include: cervical disc disorder with myelopathy, mid-cervical region (a progressive condition where a degenerated or herniated disc in the neck compresses the spinal cord, leading to loss of coordination, balance issues, and muscle weakness); Need for Assistance with personal care; muscle weakness; lack of coordination.R17's MDS (Minimum Data Set), dated 2/18/26, indicates a BIMS (Brief Interview for Mental Status) score of 15, indicating R17 is cognitively intact.On 5/21/26 at 7:47 AM, Surveyor interviewed CNA G (Certified Nursing Assistant) regarding R17. CNA G stated that a couple of week ago, R17 stated that he/she had not been changed all night. CNA G stated he/she told DON B (Director of Nursing) and RN H (Registered Nurse).On 5/21/26 at 7:57 AM, Surveyor interviewed LPN I (Licensed Practical Nurse) and asked what is done if a resident says no one has helped them all night. LPN I stated ask the cna what they noticed, is the resident soiled. Look for documentation. Talk to the resident, take care of their need. Talk to the staff the next night. Surveyor asked if anyone else is talked to. LPN I stated he/she would speak with DON B. Surveyor asked about R17. LPN I stated there was one morning where R17 claimed he/she wasn't cared for; when I spoke with the CNA it sounded like a refusal. I don't think I was the nurse on that hall, I think I had stopped to assist. The resident told the CNA and myself. I shared with the nurse, so I felt it was handled.On 5/21/26 at 8:42 AM, Surveyor interviewed RN H and asked what is done if a CNA reports that a resident has a concern with their care. RN H stated call the DON (Director of Nursing) and NHA (Nursing Home Administrator), talk to the resident, and start the grievance process. Surveyor asked about R17 voicing concern of not being changed all night. RN H stated not that I know of. Surveyor asked what would happen if this was reported. RN H stated I'd talk to the resident and tell DON B and NHA A (Nursing Home Administrator).On 5/21/26 at 9:37 AM, Surveyor interviewed R17 and asked if there had been a concern of not being cared for during the night. R17 stated yes, the CNAs shift was from 10:00 PM to 6:00 AM; usually they will come in about 3-4 times during the night; he/she had come in around 11:00 PM and asked if I was dry, I said yes, and he/she left. He/she didn't talk with me the rest of the night. He/she came back in at 5:00 AM, when the shift was almost over. He/she should've checked on me, I need to be changed a couple of times during the night, but he/she didn't check. Surveyor asked if R17 told anyone. R17 stated yes, I tell whoever is on duty.On 5/21/26 at 9:57 AM, Surveyor interviewed DON B and asked if it is a potential allegation of neglect if a resident says they didn't get changed all night. DON B stated yes, we'd need to investigate and report. Surveyor asked if it had been reported to DON B that R17 stated that a couple weeks ago R17 hadn't been changed all night. DON B stated, not that I am aware of.On 5/21/26 at 10:23 AM, Surveyor interviewed NHA A and asked if it is a potential allegation of neglect if a resident says they didn't get changed all night. NHA A stated yes, would need to self report the allegation of neglect, protect the resident through investigation of the alleged perpetrator, remove that person from the building/suspend pending investigation, interview other staff and residents. Surveyor asked if R17's concern was reported. NHA A stated no, I didn't know about this until now; it should've been reported. We did do a lot of education on May 5 and 6 regarding grievances and abuse. I will start the investigation and submit a report.

Based on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 2 residents reviewed for pressure injuries (R30). R30 was at risk for developing pressure injuries related to immobility and multiple fractures. The facility failed to implement aggressive pressure injury interventions; failed to complete weekly assessments per standard of practice; failed to provide risk and benefits despite knowledge of R30 refusing repositioning. Facility did not assess or measure R30's left gluteal pressure injury. R30 developed two stage three, and one unstageable facility acquired pressure injuries. Facility failure to ensure R30 received care consistent with professional standards of practice to prevent pressure injuries from developing or deteriorating, created a finding of immediate jeopardy that began on 2/18/25. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 3/7/25 at 10:15AM. The immediate jeopardy was removed on 3/7/25. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan Findings include: The facility's policy, titled Pressure Injury/Skin Breakdown-Clinical Guidelines states: Assessment and Recognition: *The nursing staff will, upon admission complete an evaluation of the residents skin and resulting risk factors for developing pressure injuries; for example, immobility, recent weight loss, and a history of pressure injuries. * The staff will examine the skin of a new admission and/or re-admission for ulcerations or indications of a stage 1 pressure area that has not yet ulcerated at the surface. *A standardized tool example (ex. Braden or [NAME]) will be utilized weekly for four weeks after admission and/or readmission and at least quarterly to determine risk for clinical breakdown. * The nursing staff will complete an evaluation of the skin weekly. Treatment/Management: *Based upon need and the results of the evaluations the staff will implement interventions for the prevention and care of skin issues. The IDT will review measures upon admission, quarterly and with significant change. Note: *Although poor nutritional status is associated with increased risk of pressure injury development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure injuries. There are no pressure injury dash specific nutritional measures that should be provided routinely to those with or at risk for developing a pressure injury. Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect appetite, weight, and overall nutritional balance. *As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, because of end stage heart disease or because cause-specific treatment is not advisable, not feasible, or not desired by the resident or family. Per the NPIAP (National Pressure Injury Advisory Panel) a pressure injury is defined as .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. NPIAP definitions include: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. An Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. R30 was admitted to the facility on [DATE] and has diagnoses that include wedge compression fracture of fourth lumbar vertebra (L4 is near the tailbone and wedge indicates the vertebra collapsed inward resulting in a wedge shape), Type 2 Diabetes, and muscle weakness. His most recent MDS (Minimum Data Set), dated 12/20/24, includes a BIMS (Brief Interview for Mental Status) score of 15, indicating R30 is cognitively intact. According to section GG of R30's admission MDS, dated [DATE], R30 needed substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair/bed-to-chair transfer, and tub/shower transfers. On 10/16/24, the facility conducted a Braden assessment (a tool used to assess a patient's risk of developing pressure ulcers) with a resulting score of 17, indicating R30 was at risk for developing pressure ulcers. R30's care plan states, Focus: .is at risk for skin breakdown and pressure ulcer development related to limited mobility, diabetes. Resident was admitted with multiple abrasions and open area to gluteal cleft. Refuses or removes pressure relief devices at times such as heel lifts .Goal: .will be free from new open skin concerns through the review date .Interventions: assist to turn/reposition as needed or requested (initiated 10/17/24), follow protocols for the prevention of skin breakdown (initiated 10/17/24), Roho wheelchair cushion (initiated 10/17/24), diabetic: float heels when in bed/recliner (initiated 10/17/24), inform family/caregivers of any new areas of skin breakdown (initiated 10/17/24), lotion skin PRN (initiated 10/17/24), monitor nutritional status. Serve diet as ordered and monitor and record intake (initiated 10/17/24), obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (initiated 10/17/24). Additionally, R30's care plan states, Focus: .has an ADL self care deficit related to limited mobility, impaired balance, and weakness secondary to motor vehicle accident with fractures to multiple right ribs and L4 spine .Goal: will maintain or improve current ADL function .Interventions: Bed mobility: Requires 1 staff participation to reposition and turn in bed. On 10/15/24, as part of R30's admission assessment, it was noted that there was a 0.5cm in diameter open area to R30's intergluteal cleft (the groove or crease located between the two buttocks). No further assessment, measuring, or documentation was made of this area, nor did the facility provide any documentation that this was reported to R30's physician. On 10/24/24, the facility discovered an area on R30's coccyx/sacrum, described as MASD (Moisture Associated Skin Damage) IAD (incontinence associated dermatitis). The facility assessed the wound at this time, measuring 4.19 cm x 2.42 cm (Length x Width) with 90% slough (dead tissue within a wound) and 10% epithelial tissue (new layer of skin). treatment .soap & water Primary dressing, no dressing applied. The 10/24/24 skin assessment states, Sent message to NP on 10/24/24 requesting zinc oxide to buttocks BID (twice daily) and PRN. There is no order, documentation on facility administration records or progress notes indicating that this order was fulfilled and it was being deployed nor is there documentation that any specific order was being used to address R30's coccyx/sacrum wound until 11/6/24. Of note: Facility failed to complete a weekly assessment around 10/31/24 and the next assessment and measurement was not completed until 11/4/24. 11/4/24: coccyx/sacrum 3.95 x 5.12 (MASD, 100% granulation) Treatment: cleansing solution, soap & water.other, specify zinc oxide . no secondary dressing. Progress deteriorating .practitioner notified. 11/5/24: coccyx/sacrum6.58 x 5.11 (MASD, 100% granulation) additional care: cushion, foam mattress, nutrition/dietary supplementation. Physician order on 11/6/24 indicates Cleanse sacral ulcer with cleanser, pat dry, skin prep edges, allow to dry, cover with foam dressing every 8 hours as needed. Physician orders from 11/7/24 to 11/20/24 indicate Cleanse sacral ulcer with cleanser, pat dry, skin prep to edges, allow to dry, cover with foam dressing, one time per day every other day. 11/11/24: coccyx/sacrum 5.49 x 5.72 (MASD, progress deteriorating, education explained importance of turning way over on his side off his bottom.) On 11/11/24, the facility ordered a pressure-relieving mattress for R30, with correspondence via fax to the NP (Nurse Practitioner) stating, Area on bottom looking worse. Skin prep to edges and foam dressing is what we are doing. We are ordering an air mattress for him. Non-compliant with turning off/staying off bottom. Of note: there is no evidence that the facility completed risk vs benefits with R30 despite knowing that R30 was non-compliant with turning and/or staying off his bottom. The facility did not proactively implement an air mattress until R30's wound deteriorated to an unstageable Pressure injury despite R30 having multiple fractures and needing substantial assistance with cares. On 11/12/24, the facility documented this coccyx/sacrum wound as unstageable, noting the wound was 5.64 cm x 5.81 cm, Type pressure. Stage unstageable due to slough and/or eschar. Acquired present on admission. Wound bed with 70% slough. Treatment soap & water, primary dressing foam, no secondary dressing. Additional care: cushion; incontinence management; mattress with pump; moisture control; repositioning device(s); turning/repositioning program. Progress: deteriorating. 11/13/24: 3.9 x 4.69 (Coccyx, Unstageable, 70% slough) 11/19/24: 2.27 x 3.33 x 0.1 (Sacrum, Unstageable, 100% slough, in house acquired) It should be noted that the facility documented that R30's wound was on his coccyx until 11/19/24 at which time this same area was referred to as the sacrum. The coccyx wound is labeled as upon admission, however, once the wound is assessed as a sacrum wound, it is documented as in-house acquired. Physician orders from 11/20/24 to 1/9/25 indicate 1. Cleanse with cleanser, pat dry 2. Skin prep to edges and allow to dry 3. Cut to fit wound base Hydrofera Blue Transfer 4. Cover with foam dressing, one time per day every other day. 11/26/24: 2.94 x 6.18 x 0.1 (Sacrum Unstageable, 60% slough, 40% epithelial) Of note R30's wound has almost doubled in width. 12/9/24: 1.02 x 1.13 (Sacrum Unstageable, 70% slough, 30% epithelial) education: resident educated on continuing to offload pressure to the sacral area and to alert staff with urge to void or BM. Of note, there are 12 days between 11/26/24 and 12/9/24 measurement/assessment. 12/19/24: 1.79 x 1.05 (sacrum, Stage 2, 100% epithelial) (Of note, the standard of practice, does not allow for the down staging of pressure injuries. There is 10 days between this measurement and R30's last measurement on 12/9/24.) 12/30/24: sacrum 0.87 x 0.73 (Unstageable, 100% epithelial) Of note: there are 11 days between this measurement and R30's last measurement on 12/30/24. 1/6/25: sacrum 1.75 x 1.1 (Healed) Of note: the facility measured this area as 1.75x1.1, but the facility is calling it healed. The facility was unable to provide any documentation that R30's coccyx/sacrum wound was assessed between 11/26/24 and 12/9/24 and between 12/19/24 and 12/30/24. Additionally, on 11/22/24 R30 developed what the facility called MASD, IAD (Incontinence Associated Dermatitis) on his right gluteal fold (Right ischial tuberosity). The initial assessment of the wound was 4.24 x 3.86 with light sanguineous/bloody exudate. Additional documentation shows (L x W in centimeters with facility-documented type of wound): 11/27/24: 5.14 x 4.13 (MASD-IAD, 10% granulation, 90% slough) Location ischial tuberosity. 12/9/24: Right ischial tuberosity 3.73 x 2.2 (MASD-IAD, 100% slough) Of note: there are 11 days since R30's last measurement on 11/27/24. Additionally, R30 required transfer to the hospital on 12/14/24 due to a UTI (Urinary Tract Infection) and returned to the facility on [DATE]. Upon return from the hospital, R30 was put on Juven powder twice daily and house supplement three times daily between meals. The coccyx/sacrum and gluteal wound were not reassessed upon returning to the facility on [DATE] until 12/19/24. 12/19/24: Right ischial tuberosity 2.75 x 2.7 (MASD-IAD, 100% slough) 1/6/25: Right ischial tuberosity 3.4 x 2.49 (MASD-IAD, 20% granulation, 80% slough). Of note, there are 18 days between R30s last assessment on 12/19/24. R30's physician orders 1/9/25 to 2/1/25: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Cut to fit wound base Puracol Ag 4. Cover with foam dressing, one time per day every other day and as needed. (It is important to note, that the physician orders indicate bilateral buttock wound care meaning there are wounds to both of R30's buttocks.) 1/13/25: Right ischial tuberosity 2.15 x 2.22 with 0.1 depth (MASD-IAD, 90% slough, 10% epithelial) 1/20/25: Right ischial tuberosity 1.96 x 1.92 (MASD-IAD, 20% granulation, 80% slough) 1/31/25: Right ischial tuberosity 3.09 x 2.61 (MASD-IAD, 100% slough) This is 11 days after the last assessment. R30's Physician orders: 2/1/25 to 2/7/25: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Apply Medi-honey 4. Cover with foam dressing, one time a day every other day for wound care and as needed. 2/6/25: Right ischial tuberosity 1.94 x 2.13 (MASD-IAD, 50% granulation, 50% slough) R30's Physician order: 2/8/25 to 2/20/25: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Apply zinc barrier cream to bases 4. Cover with foam dressing, one time per day every other day and as needed. 2/12/25: Right ischial tuberosity 2.38 x 2 with 0.1 depth (MASD-IAD, 100% slough) 2/18/25: Right ischial tuberosity 2.92 x 2.25 with 0.1 depth (Stage 3, 100% slough) education: educated resident to alert staff when having urge to void or defecate and also on the importance of offloading pressure to area. R30's Physician orders: 2/20/25 to present: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Pack lateral wound bases with collagen powder when available 4. Cover with foam dressing, one time per day every other day and as needed. 2/25/25: Right ischial tuberosity 2.17 x 9.03 (Stage 3, tissue type unknown/not assessed) The facility did not have any documentation that R30's right gluteal/ischial tuberosity pressure injury was assessed between 11/27/24 and 12/9/24 or 1/20/25 and 1/31/25. Of note, it was identified by the facility that R30 had developed a pressure injury on his left gluteal. This was evident in pictures that accompany facility wound assessments and confirmed on 3/3/25 at 10:40 AM in an interview with RN D (Registered Nurse), who conducts most of the wound care at the facility and is also a nurse manager. At this time, RN D stated that although the facility was aware of the left gluteal pressure injury, they did not assess or measure this wound until today (3/3/25) and assessed it to be a stage 3 pressure injury. Of note, this is the third facility acquired pressure injury for R30. On 2/25/25, R30 would not allow surveyors to observe his pressure injuries when approached. On 2/26/25 at 2:01 PM, Surveyor interviewed RN D who stated that it was her interpretation that when a wound has slough, it is now a stage 3. When asked about the inconsistencies with the assessments for R30's coccyx/sacrum wound (unstageable to stage 2) and left heel (diabetic to unstageable pressure), RN D indicated that the facility did not have a wound certified nurse and those that were at the facility did the best that they could with their judgement. RN D also indicated that R30's gluteal fold wound went from MASD-IAD to a stage 3 pressure injury due to noticing the way he sat in his chair and seeing where the injuries on his bottom were in line with boney prominences. Additionally, RN D stated that she believed the 10/15/24 skin assessment referring to the 0.5 cm open area on the intergluteal cleft was most likely the start of the coccyx/sacrum wound but there was not any follow up with the physician or NP and there was no further assessment. RN D indicated the NP should have been updated on 10/15/24 regarding this open area. RN D also indicated that the facility generally implements air mattresses as a reactive measure rather than a proactive measure, even though R30 was immobile in his bed and relied on staff for mobility and transfers. On 2/26/25, Surveyor gathered additional interviews: *At 2:31 PM, CNA U (Certified Nursing Assistant) stated that R30 is completely dependent on staff and needs help to reposition when in bed. CNA U stated that R30 should be repositioned every 2-3 hours but is not sure if this is documented anywhere. CNA U indicated that she would tell the nurse if R30 refused repositioning. *At 2:38 PM, CNA T stated that R30 requires 2 people to get in and out of bed. CNA T stated that R30 can roll himself in bed, but sometimes needs help and definitely needs 1 person on the night shift. CNA T stated that they try to reposition R30 4 times per shift (on an 8-hour shift). CNA T indicated that she would tell the nurse if R30 refused to be repositioned but wasn't sure if repositioning gets documented anywhere. *At 2:51 PM, CNA I stated that R30 needs 2 people to get in and out of bed and needs staff assistance to reposition in bed. CNA I stated that when R30 is out of bed, they will lay him down after meals. Additionally, CNA I indicated that R30 should be repositioned every 2 hours and she would tell the nurse if he refused but was unaware if this gets documented or if the repositioning is being done consistently. On 2/26/25 at 1:31 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator). Both DON B and NHA A indicated that air mattresses are put into place as a reactive measure, rather than a proactive measure. DON B indicated that there were other measures in place before the air mattress such as repositioning. Additionally, DON B stated that it was her expectation that staff be repositioning R30 every 2 hours. When asked if repositioning was being documented and tracked to ensure that it was being completed, DON B indicated that they would not have documentation on that as it was an as needed intervention. Also, DON B indicated that it is her expectation that any open area on a resident be assessed at least once every 7 days. On 3/7/25 at 10:42 AM, Surveyor interviewed NP V (Nurse Practitioner) via phone regarding R30's wounds. NP V indicated that R30 is a complicated case and is high risk for skin conditions due to being diabetic, with neuropathy, spinal stenosis and polyneuropathy. NP V indicated R30 is significantly impaired due to limited mobility and being a very high risk for skin breakdown. NP V indicated she sees R30 weekly. NP V indicated she saw R30 today (3/7/25). NP V indicated R30 has a pressure injury on both ischial tuberosities, and that R30 has two total wounds. NP V indicated she visited R30 on 10/18/24 related to his significant injuries after his accident and was having a difficult time with pain management. NP V indicated on 11/1/24, R30 was seen again for pain management due to being in pain in certain positions and he was leaning due to the pain. NP V indicated she saw R30 on 11/12 and noted that staff made multiple attempts with interventions, and he frequently refused and would remove his boot. NP V indicated that R30 understood that his wound was getting worse. NP V indicate R30's wound was worsening due to noncompliance and he was educated on following interventions. NP V indicated on 11/19/24, R30 had a sacral ulcer and R30 was difficult with repositioning and refused. NP V indicated she discussed the importance of repositioning with R30. NP V indicated on 11/26/24, R30's pain was improving and continued to have the sacral area. NP V indicated R30's groin was mentioned, but gluteal fold would be a better location. Surveyor asked NP V if she observed this area, NP V indicated she viewed the area through nursing photos with wound rounds. NP V indicated is unable to describe what the areas looked like due to not seeing the wound. Surveyor asked NP V about when R30's wounds changed from MASD to a pressure injury. NP V indicated the left groin was actually the left ischial tuberosity and the right gluteal was the ischial tuberosity as well. NP V indicated it is difficult to say when it changed to pressure due to R30 being so high risk for pressure injuries. NP V indicated once they started R30 on prednisone his wounds started changing weekly and his risk was extremely high this whole time. Surveyor asked NP V what her expectations are for how often to reposition R30. NP V indicated repositioning and pressure have been an issue this whole time due to R30 being so neuropathic and having no sensation but pain. NP V indicated R30 was not worried about wounds he couldn't feel. Surveyor asked if an air mattress should have been in place since admission given his high risk for PIs. NP V indicated No, as R30 is up and out of bed and would encourage him to lay down, he wants to be up in his chair. Surveyor asked NP V if she had access to the facility wound assessments, NP V replied yes. Surveyor asked NP V to review the 12/19/24 wound assessment photo. NP V reviewed the photo. Surveyor asked NP V if she could tell Surveyor what she sees in the photo. NP V indicated slough tissue with granular tissue. Unable to say percentage due to photo. Surveyor asked NP V if she could see two wounds in the photo. NP V replied, yes. Surveyor asked the location, NP V replied ischial tuberosities. Surveyor asked what type of wounds they were. NP V indicated it was hard to say pressure due to him having incontinence. Surveyor asked if the wounds are circular in shape. NP V indicated yes, circular in shape is a characteristic of pressure. NP V indicated in previous photos, R30 has scar tissue present on the left ischial area and that R30 is at high risk for pressure. Surveyor asked about having slough with MASD, NP V replied yes, as it's dead tissue sloughing off. Surveyor asked how often R30 should be repositioned, NP V replied the facility expectation is every 2 hours. Surveyor asked what R30's left ischial wound looked like today. NP V indicated today (3/7/25), R30's left ischial wound was initially largely slough covered, so it was an unstageable and now it's 90% granulation and 10 % slough with 3cm of scar tissue around it in a week. NP V wanted Surveyor to note that R30 was incontinent of stool three times during wound care today. Surveyor asked NP V about the area measuring 0.5cm on admission. NP V indicated she would expect the hospitalist to address the open area on admit. NP V indicated expected wounds to be measured at least weekly. R30 was at risk for developing pressure injuries related to immobility and multiple fractures. The facility failed to implement aggressive pressure injury interventions; failed to complete weekly assessments per standard of practice; failed to provide risk and benefits despite knowledge of R30 refusing repositioning. Facility did not assess or measure R30's left gluteal pressure injury. R30 developed two stage three, and one unstageable facility acquired pressure injury. The failure to ensure R30 received care consistent with professional standards of practice to prevent pressure injuries from developing or deteriorating led to serious harm for R30, which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 3/7/25 when it completed the following: *The facility failed to implement robust interventions to prevent PI development for R1, The facility failed to provide risk vs benefits for R1 when he declined. Other residnets potentially affected would be resdents with a Braden of less than 15. * Skin Assessment completed for each resident 3.7.25 * Braden Assessment completed for each resident 3.7.25 * Medical Director on site 3.7.25 completed wound rounds assessment with DON, determined etiology, and validated appropriate treatment in place for R1 and all resident with wounds. * Residents who scored <15 on Braden assessments have had care plans reviewed and updated with appropriate interventions based on areas of concern identified on Braden Assessment 3.7.25 * Educated Nursing Staff (Licensed and CNA) on pressure injuries - including risks, treatment guidelines, interventions & care strategies, wound care guidelines, and nutritional choices and support, educated on documentation of risk/benefit conversations in Refusal of Care progress note on March 7, 2025, or before staff next shift worked, starting March 7, 2025. * F686 - Review of F686 Pressure Injury Treatment Guidelines completed by Medical Director 3.7.25 Review of Policy Pressure injury/skin breakdown - clinical guidelines reviewed by Medical Director 3.7.25 * Review of F686 Pressure Injury Risk Assessment Guidelines by Medical Director 3.7.25 * Initiation and education of Progress note specific to Refusals of Care and Risk/Benefits discussion to be used as documentation template for residents who refuse skin interventions 3.7.25 or by next shift worked by DON or RN designee. * F686 - Medical Director and/or Wound NP to review wound assessments weekly with facility nursing team either bedside at the facility or remotely to ensure thorough and accurate assessments, treatments remain appropriate, and standards of practice are maintained. Weekly reviews to continue x 4 weeks unless concerns are noted during reviews. After the Provider oversight DON/Designee will audit 4 wound assessments & care plans weekly x 4 weeks then 2 wound assessments weekly x 2 weeks. Audit result will be reviewed with the Medical Director during QAPI. Audits will be discontinued based on QAPI committee recommendations. Ad hoc QAPI held with Medical Director, Acting Administrator, DON, and Governing Body. Action plans reviewed, discussed and agreed upon at 1:55pm on 3.7.25.

Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the ability to affect all 38 residents. Food items were observed to be spoiled. Scoops were found in containers of sugar. Nutritional supplements were found without use by dates. Four Sysco Imperial Strawberry Shakes were found in the medication room refrigerator with no use by date. Findings include Example 1 On 2/24/25 at 9:24 AM, Surveyor observed in the facility kitchen's refrigerator, along with DM C (Dietary Manager), an unoppened and unchopped bag of fresh parsley with a received date of 1/21/25. Portions of the parsely were visbly brown and slimey. Additionally, Surveyor observed a bag of unopened lettuce with a received date of 2/11/25 that appeared to be slimey and discolored. DM C stated at this time that the lettuce and parsley should be thrown away. Example 2 On 2/24/25 at 9:42 AM, Surveyor observed in the facility kitchen, along with DM C, 3 containers, 1 each of flour, brown sugar and sugar with scoops in each container. DM C indicated to Surveyor at this time that the scoops should not be in the containers as it could be a cross contamination issue. 50228 Example 3 On 2/25/25 at 1:31 PM, Surveyor observed four Sysco Imperial Strawberry Shakes (nutritional supplement) in the medication room refrigerator with no use by date. Surveyor interviewed RN E (Registered Nurse) and asked when the shakes expire / when the shakes should be disposed of. RN E stated unable to tell as the shakes don't have labels. On 2/26/25 at 10:09 AM, Surveyor interviewed NHA A (Nursing Home Administrator) and DON B (Director of Nursing) and asked if there is no label on a supplemental shake, would the staff be able to accurately determine when it needs to be used by / disposed of. NHA A and DON B stated no. Surveyor asked if there should be a use by date on supplemental shakes. NHA A and DON B stated yes.

Based on interview and record review, the facility did not ensure the facility wide assessment developed by the facility included all relevant details to ensure the facility provided care and services to residents to meet their individual needs within the facility's identified resources. This has the potential to affect all 38 residents residing in the facility. The Facility Assessment did not indicate: -the facility's resident capacity -the care required by the resident population considering the types of disease, conditions, physical and cognitive disabilities, overall acuity -Staff competencies that are necessary to provide the level and types of care needed for the resident population -Physical environment, equipment services, and physical plant considerations that are necessary for care of the population -Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services -The facilities resources, including but not limited to, all buildings and/or other physical structures and vehicles, equipment (medical and non-medical) -Services provided, such as therapy, pharmacy, and specific rehabilitation therapies -All personnel, including managers, staff (both employees and contracted employees), and volunteers as well as their education and/or training and competencies to provide resident care -Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during normal operations -Health information technology resources such as systems for electronically managing patient records and electronically sharing information with other organizations This is evidenced by: The facility's policy titled, Facility Assessment F 838, dated 10/2024, states, in part: Policy Statement: The community will conduct a facility wide assessment, review it periodically and update it annually. Policy Interpretation and Implementation: 1. Purpose - to determine what resources are necessary to care for our residents during both day-to-day operations and emergencies. 2. Updates occur periodically and at least annually. 3. Include: a. The number of residents and the facility's resident capacity; b. The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that apply to the current population, c. The staff competencies that are necessary to provide the level and types of care needed for the resident population, d. The physical environment, equipment, services and other physical plan consideration that are necessary for this population, and e. Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to activities and food and nutrition services. 4. List, at a minimum the following resources: a. All buildings and/or other physical structures and vehicles; b. Equipment (medical and non-medical); c. Services provided; d. Staff and their associated competencies required; e. Contracts for normal and emergent services; and f. Health information services . Surveyor reviewed the facility document titled Facility Assessment, dated January 2025. Surveyor noted the document contained several categories, the first being Resident Population Profile, dated 12/21/23-12/20/24 that includes sections labeled number of admission/stays, % of admissions/stays, frequency relative to benchmark. The actual benchmark is not listed for any category. Other categories included are Diseases, Conditions & Treatments, Acuity-Frequency of Potentially High-Risk Treatments, Acuity-Care Requirements, Cognitive, Mental & Behavioral Status, Cultural, Ethnic, & Religious Factors. None of these categories had a listed benchmark which the facility had assessed their facility to be capable of accepting. Additionally, the staffing section is titled Staffing, Training, Services & Personnel, containing categories titled Overall Staffing, Staff/Training/Competencies, and Services. All categories are marked Evaluated with no additional information or other staffing needs quantified. Finally, the sections marked Physical Environment, Technology, Equipment have the same categories marked Physical Environment, Technology, and Equipment, and all sections are marked Evaluated with no actual benchmark or quantity of equipment or technology listed. (Of note: Quite often the Frequency Relative to Benchmark is indicated as High or Very High without any reference to the actual benchmark) On 2/26/25 at 11:15 AM, Surveyor asked NHA A (Nursing Home Administrator) for any additional information or documentation related to the facility assessment. NHA A indicated there was none, and that all information was provided. On 2/26/25 at 11:30 AM, Surveyor advised NHA A that Surveyors were looking for documentation stating specific numbers of residents that can be accepted with different conditions, therapies such as IVs, and equipment needs. NHA A indicated she would look for additional documentation. On 2/26/25 at 12:01 PM, NHA A provided Surveyor with the same documentation that was previously described and advised that the information Surveyor was looking for was contained in a paragraph within the previously provided documentation. Surveyor reviewed the paragraph again and could find no additional information specifying the quantity of assessed resident population, staffing, or physical environment needs. Another Surveyor also reviewed the documentation looking for the required information to ensure nothing was missed. Another Surveyor confirmed the required information was not contained within the documents provided. No additional information was provided as to why the facility did not conduct and document a complete facility-wide assessment to determine what resources are necessary for the care of its residents. The facility assessment must reflect the resident population, and the resources needed to care for this population.

Based on observation, interview and, record review, the facility did not 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. This has the potential to affect the census (38). The facility is not monitoring the temperature of 3 of their 5 water heaters as part of their control measures for Water Management Program. The facility's policy and procedure for Pneumococcal Vaccine is not up to date. A breach in infection control was observed with R236, R16, R7, and R22. This is evidenced by: Example 1 Per Centers for Disease Control and Prevention (CDC), 3/15/24 documents, in part: .Cold water guidance: Store and circulate cold water at temperatures below 77 F, although Legionella may grow at temperatures as low as 68 F (20 C). Hot water guidance: Store hot water at temperatures above 140 F (60 C). Ensure hot water in circulation doesn't fall below 120 F (49 C) and recirculate hot water continuously, if possible . The Facilities Water Management Program dated as reviewed 1/21/25 documents in part: Description of Building Water System .Cold water is heated to 140 degrees by two joined 120-gallon water heaters in the water heater utility room that serves shower and faucet fixtures in room on all three wings. Cold water is also delivered to a 120-gallon water heater in the water heater utility room that serves the kitchen. Cold water is also delivered to an 80-gallon water heater in the 300-wing janitor closet that serves the 300-wing spa. Cold water is also delivered to an 80-gallon water heater in the laundry room that serves the laundry room . Logbook Documentation from 2025 includes the following, in part: 1/9/25- Laundry= 155.1 degrees, Kitchen= 147.1 degrees, 300 Spa= out of order, mixing valve temp= 132 degrees 1/15/25- Laundry= 155 degrees, Kitchen= 147.7 degrees, 300 Spa= closed for repairs, mixing valve temp= 131 degrees 1/24/25- Laundry= 150 degrees, Kitchen= 147.2 degrees, 300 Spa= out of order, mixing valve temp= 132 degrees 1/29/25- Laundry= 151 degrees, Kitchen= 146.2 degrees, 300 Spa= out of order, mixing valve temp= 131 degrees 2/6/25- Laundry= 155 degrees, Kitchen= 145 degrees, 300 Spa= 112.1, mixing valve temp= 130 degrees 2/13/25- Laundry= 150 degrees, Kitchen= 147.5 degrees, 300 Spa= 113.1, mixing valve temp= 133 degrees 2/20/25- Laundry= 155 degrees, Kitchen= 146 degrees, 300 Spa= 113.2, mixing valve temp= 131 degrees On 2/26/25 at 10:19 AM, Surveyor interviewed Maintenance K. Surveyor asked Maintenance K what control measures are being monitoring routinely to prevent Legionella, Maintenance K said weekly water temperatures. Surveyor asked Maintenance K are the temperatures of the water heaters being check regularly, Maintenance K stated yes technically, the laundry and kitchen each have their own and the rest of the building runs off of 3 other water heaters. Surveyor asked Maintenance K what those water heaters would be labeled on the temperature documentation received, Maintenance K said kitchen, laundry, mixing valve (has 2 water heaters) and the 300 spa (has 1 water heater). Surveyor asked Maintenance K if the temperatures recorded for the mixing valve and the 300 spa were at the water heaters themselves, Maintenance K replied no, those are not, the kitchen and laundry are. Surveyor asked Maintenance K what temperature water must heat to in order to prevent Legionella, Maintenance K stated, Minimum 130 degrees or is it 116 degrees. Of note, 140 degrees is the temperature required to prevent Legionella. On 2/26/25 at 3:28 PM, Surveyor interviewed NHA A (Nursing Home Administrator). Surveyor asked NHA A would you expect the control measures for your Water Management Program to be documented, NHA A stated yes. Example 2 The CDC's Pneumococcal Vaccine Recommendations dated 10/26/24 documents in part: .CDC recommends pneumococcal vaccination for children younger than 5 years and adults [AGE] years or older . The Facilities Policy and Procedure entitled Pneumococcal Vaccine F883 dated 10/24, documents in part: .Pneumococcal Vaccine Schedule for Adults greater than or equal to [AGE] years old . On 2/26/25 at 3:31 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B do you know the current guidance for pneumococcal vaccine, DON/IP B stated there's the Prevnar 13, Pneumovax 23, and Pneumococcal conjugate 20 for adults over [AGE] years old. Surveyor asked DON/IP B if she is aware of any new guidance after the new addition of the newest vaccine, DON/IP B said not that I am aware of. 49434 Example 3 On 2/25/25 at 1:27 PM, Surveyor observed CNA J (Certified Nursing Assistant) performing Peri Care for R236. R236 was on a toilet at the start of the process. CNA J performed hand hygiene and donned gloves. CNA J then assisted R236 into a standing position and ensured resident safety while standing. CNA J then wiped the perineal area from front to back with several clean wipes. After CNA J, had finished cleaning the resident, she pulled R236's brief and pants up without cleaning her hands or changing gloves. After the resident's clothes were adjusted, CNA J then removed her gloves and performed hand hygiene. On 2/25/25 at 1:35 PM, Surveyor interviewed CNA J. Surveyor asked CNA J if hand hygiene should be performed before touching the resident's clothes after performing peri-care. CNA J, states yes. 50228 Example 4 On 2/24/25 at 11:21 AM, Surveyor observed CNA G (Certified Nursing Assistant) assisting R16 with pericare. During this observation, CNA G performed pericare for R16's front, turned R16 to the side touching R16's bed linens and clothing, touched the wipes package and obtained more wipes, performed pericare for R16's backside, and applied barrier cream. There was no removal of gloves with hand hygiene after contact with bodily fluids prior to touching bed linens, clothing, wipes package, or barrier cream. Surveyor interviewed CNA G regarding infection control. CNA G stated that gloves are contaminated after performing pericare and should have been removed and hand hygiene performed prior to touching resident items and applying barrier cream. On 2/26/25 at 10:22 AM, Surveyor interviewed DON B (Director of Nursing) and asked about hand hygiene and pericare. DON B stated that hand hygiene is expected prior to task, when changing gloves, when moving from dirty to clean site, and when task is complete. Surveyor asked if resident's clothing, linens and supplies should be touched without hand hygiene. DON B stated no. Example 5 On 2/24/25 at 1:51 PM, Surveyor observed CNA H assisting R7 with pericare. During this observation, CNA H removed a mechanical device transfer sling from under the resident and threw the sling onto the floor. CNA H performed pericare for R7's front, turned the R7 to the side touching R7's bed linens and clothing, touched the wipes package and obtained more wipes, then performed pericare for R7's backside. R7 complained of discomfort to R7's bottom. CNA H took the walkie talkie from CNA H's waistband and called the nurse to the room. CNA H gathered the two packages of wipes from R7's bed, opened R7's bedside cabinet and put the wipes away. There was not removal of gloves with hand hygiene after contact with bodily fluids prior to touching bed linens, clothing, wipes packages, walkie talkie, or bedside cabinet. Surveyor interviewed CNA H regarding infection control. Surveyor asked if the floor is contaminated. CNA H stated yes. Surveyor asked if the mechanical device transfer sling should be on the floor. CNA H stated no. Surveyor asked about infection control with pericare. CNA stated that gloves are contaminated after performing pericare and should have been removed and hand hygiene performed prior to touching resident items. On 2/26/25 at 10:22 AM, Surveyor interviewed DON B and asked about hand hygiene and pericare. DON B stated that hand hygiene is expected prior to task, when changing gloves, when moving from dirty to clean site, and when task is complete. Surveyor asked if resident's clothing, linens, supplies, and walkie talkie should be touched without hand hygiene. DON B stated no. Surveyor asked if the floor is considered contaminated. DON B stated yes. Surveyor asked if a transfer sling should be placed on the floor. DON B stated no. Example 6 On 2/26/25 at 11:37 AM, Surveyor observed CNA I assisting R22 with pericare. During this observation, CNA I performed pericare, then CNA I removed one glove, touched the box of gloves with the gloved hand and removed a new glove with the ungloved hand, then applied the new glove to the gloveless hand with the gloved hand. CNA I then assisted R22 with adjusting clothing and transferred R22 to the wheelchair with use of the mechanical sit to stand device. R22 removed both gloves and attempted to cleanse hands with hand sanitizer mounted to the wall in R22's room. CNA I stated the sanitizer was empty. CNA I opened R22's bedroom door, pushed the mechanical device out of the room, and asked Surveyor if anything else was needed before going on to the next resident. Surveyor interviewed CNA I about infection control. CNA I stated that gloves are contaminated after performing pericare and should be removed and hands cleansed prior to touching resident items. Surveyor asked if hand sanitizer is not available is there another option for hand hygiene. CNA I stated hand hygiene could be performed in the resident room with soap and water at the sink. On 2/26/25 at 10:22 AM, Surveyor interviewed DON B (Director of Nursing) and asked about hand hygiene and pericare. DON B stated that hand hygiene is expected prior to task, when changing gloves, when moving from dirty to clean site, and when task is complete. Surveyor asked if staff should remove one glove, obtain another glove, and apply without performing hand hygiene. DON B stated no. Surveyor asked if resident's clothing, supplies, mechanical transfer device, wheelchair, and door should be touched without hand hygiene. DON B stated no.

Based on interview and record review, the facility failed to immediately consult with a physician when needing to alter treatment for 1 of 13 (R8) residents reviewed for physician notification. R8 experienced an episode of coughing so much phlegm it caused him to have emesis (vomiting) in October 2024. Additionally, R8 had a 4-pound weight increase in one day in February 2025, which is a significant change in relation to R8's medical conditions, which can indicate worsening respiratory symptoms. The facility did not call the on-call physician to allow for alteration of treatment if the physician deemed it necessary. This is evidenced by: The facility policy titled, Guidelines for Notifying Physicians of Clinical Problems, dated 10/2024, states, in part: . The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. The Charge Nurse or supervisor should contact the Attending Physician at any time if they feel a clinical situation requires immediate discussion and management . Immediate Notification (Acute) Problems: The following symptoms, signs and laboratory values should prompt immediate notification of the Physician, after an appropriate nursing evaluation. Immediate implies that the Physician should be notified as soon as possible, either by phone or by pager. These situations include: . 3. The following symptoms: a. Sudden onset OR a marked change (for example, much more severe) compared to usual (baseline) status, AND are b. Unrelieved by measures which have already been prescribed (e.g. Nitroglycerin (lowers blood pressure) for chest pain, antacid for abdominal discomfort) . The facility uses eINTERACT as their standard of practice. According to INTERACT, dated 2017, a cough with new sputum production requires immediate MD (Medical Doctor) notification. R8 was admitted to the facility on [DATE], with an initial admitted [DATE], with diagnoses that include, in part: Acute on Chronic Systolic Heart Failure with intermittent and sudden acute symptoms, Chronic Obstructive Pulmonary Disease (a condition caused by damage to the lungs and limits airflow), Type 2 Diabetes, Cirrhosis of liver, and hypertension (high blood pressure). R8's most recent Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 12/15/24 states that R8 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating that R8 is cognitively intact. On 10/28/24 at 11:39 PM, a Progress Note is written that states, in part: .He stated that last night he 'Was coughing up so much phlegm' It caused him to have an emesis. He stated the phlegm has been a clear with a yellow [NAME] to it .Message left for PCP (Primary Care Provider). A fax, dated 10/28/24, from nursing home to MD S (Medical Doctor), indicates a report of R8's coughing with sputum without notification of reported emesis. The reply from the physician was sent from the clinic on 10/29/24 at 2:06 PM, after R8 had been sent to the emergency room . (Of note: The facility's standard of practice for change in condition indicates the physician should have been notified immediately. Additionally, according to regulation, the facility must consult with the resident's physician, not just notify. A fax to the physician is not immediate notification.) R8' Physician Orders indicate, in part: Daily weight in the morning related to ACUTE ON CHRONIC SYSTOLIC (CONGESTIVE) HEART FAILURE. Order status: Active. Start date: 12/7/2024 06:00. R8's Weight Documentation indicates, in part: 2/13/25 at 10:35 AM: 172.2 lbs. (Standing) 2/14/25 at 1:57 PM: 176.4 lbs. (Standing) On 2/15/25 at 6:10 PM, a Progress Note states, in part: Resident's weight increased from 172.2 to 176.2 from 2/13- 2/14. Unclear if MD was notified. Weight this AM was 175.2. Resident's breathing labored and tachypneic (High respiratory rate) in the 40s, O2 (Oxygen) saturation of 85% on 2.5 L (Liters) via NC (Nasal Cannula) . A fax, with an illegible date in February 2025, indicates a general update on the resident was provided including the weight increase. However, no response was documented. There is a mark on the bottom of the page that may be a signature that is dated 2/17/25. The response fax is dated 2/17/25 at 3:26 PM. On 2/26/25 at 3:42 PM, Surveyor interviewed LPN O (Licensed Practical Nurse) and asked what situations she would immediately notify a physician. LPN O indicated she would immediately notify a physician for a change in condition, urinary tract infection symptoms, a fall, significant bleeding, or high or low blood sugars. Surveyor asked LPN O what it means to immediately notify a physician. LPN O indicates she would call a physician within a couple of hours after she was able to assess the resident. Surveyor asked LPN O what standard of practice the facility uses for change in condition. LPN O indicates she references binders at the nurses' station to determine what requires notification. Surveyor asked LPN O if a resident is acutely coughing up sputum and reporting emesis, does this require immediate physician notification. LPN O indicates that would be pretty urgent and would call if as needed treatments were attempted and did not resolve the resident's symptoms. On 2/26/25 at 5:02 PM, Surveyor interviewed DON B (Director of Nursing) and asked what it means to immediately notify a physician. DON B stated as soon as practicable. Surveyor asked DON B in what situations should staff immediately notify a physician. DON B indicated with a change in condition or abnormal vital signs. Surveyor asked DON B if a fax would be acceptable or if a physician should be called. DON B indicated that it depends on the situation. Surveyor asked what change of condition standard of practice the facility follows. DON B stated the facility follows eINTERACT. Surveyor asked DON B if a resident is acutely coughing up sputum to the point they are having emesis, is an immediate physician notification needed. DON B stated, yes. Surveyor asked DON B if a resident who has CHF and has a weight change of 4 pounds in one day would require immediate physician notification. DON B indicated she would expect staff to call the physician immediately.

Based on interview and record review the facility did not ensure services meet professional standards of quality for 1 of 1 residents (R237) reviewed for wound vac therapy (a device that provides negative pressure wound therapy to promote healing). R237 was admitted to the facility with a wound vac, the facility failed to ensure there were physician orders for the provisions of care for the wound vac in the medical record. The facility policy titled, Guidelines for Notifying Physicians of Clinical Problems, dated 10/2024, states, in part: . The immediate (acute) and non-immediate (sub-acute) problems listed below are not meant to be all-inclusive. The Charge Nurse or supervisor should contact the Attending Physician at any time if they feel a clinical situation requires immediate discussion and management . Immediate Notification (Acute) Problems: The following symptoms, signs and laboratory values should prompt immediate notification of the Physician, after an appropriate nursing evaluation. Immediate implies that the Physician should be notified as soon as possible, either by phone or by pager. These situations include: . 3. The following symptoms: a. Sudden onset OR a marked change (for example, much more severe) compared to usual (baseline) status, AND are b. Unrelieved by measures which have already been prescribed (eg. Nitroglycerin (lowers blood pressure) for chest pain, antacid for abdominal discomfort) . Surveyor requested a policy regarding wound-vacs and the facility reported they did not have one. R237 was admitted to the facility on [DATE] with diagnosis that include, in part: sepsis (widespread infection causing damage to tissues and organs) due to methicillin resistant staphylococcus aureus (Antibiotic-resistant bacteria), infection following a procedure-deep incisional surgical site, and type 2 diabetes. R237's Admission Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 1/17/25, indicates R237 has a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating he is cognitively intact. Surveyor reviewed R237's Physician orders. No orders, active or inactive, were able to be found regarding R237's wound-vac. Surveyor reviewed R237's Comprehensive Care Plan. Focus: [R237] is at risk for skin breakdown and pressure ulcer development related to diabetes, incontinence, limited mobility, morbid obesity, anticoagulation use. Surgical incision dehiscence to lumbar region which has interventions that include, in part, .Change wound vac dressing as ordered. Notify MD with any changes noted to area . Surveyor reviewed R237's document titled, Hospitalist Discharge Summary, dated 2/14/25, indicates: R237 was diagnosed and treated for severe sepsis secondary to lumbar surgical site infection. Additionally, a follow up appointment was scheduled for 2/26/25 for: 2 week post-op, For wound vac removal and incision check. The document also states: . Wound Care/Home Nursing: Keep wound vac in place until follow up with neurosurgery . Surveyor reviewed R237's document titled, After Visit Summary - Transition, dated 2/14/25, states, in part: . Discharge Instructions Lumbar Fusion: . Incision Care: [Brand Name] wound vac in place. Do NOT remove or get wet. For trouble shooting please[sic] call wound care clinic. Shower/Bath: May NOT shower or submerge wound vac at any time. May take sponge bath only. Do NOT get any water under wound vac . (Of note: None of this information was contained on the physician orders, plan of care, or banner in R237's electronic chart.) On 2/25/25 at 2:09 PM, Surveyor interviewed R237 regarding his ER transfer. Surveyor asked R237 how his transfer has affected him. R237 indicated he was so stressed he had an anxiety attack the day after he went to the ER and the facility had to administer oxygen to him because he was so short of breath. Surveyor asked R237 if this transfer was having any continued effects. R237 states, I'm still stressed about it talking to you today, and indicated that he wants answers, and he doesn't know why he needed to go to the ER, especially since the ER doctor said he didn't need to be there. At this time, the facility Dietician entered the room, requesting to speak to the resident. Surveyor advised the resident they would come back so the Dietician can speak with him regarding his care. The Dietician ask R237 if he was okay. R237 indicated he was very upset and didn't feel like explaining the situation to her. On 2/25/25 at 4:33 PM, Surveyor returned to interview R237 regarding his ER transfer. During this interview, R237 indicated he was stressed regarding the financial implications of his transfer. He also stated, I went through hell with this process . I just hated getting passed around like a piece of meat . On 2/22/25 at 9:22 PM, a Progress Note is written by RN P (Registered Nurse) that states, in part: . Wound vac in place. Functioning as ordered . A Progress Note is written by NP Q (Nurse Practitioner) with an effective date of 2/22/25 at 11:00 PM and a Date of Service listed as 2/23/25. The visit type is described as: Telehealth-Asynchronous. The note states: Patient has a wound vac on an infected[sic] surgical wound on his back. The[sic] wound vac quit working[sic] last night as it only had a 14 day working life and the nurse tried to call the surgeon's office, and then she was directed to infectious disease, which directed her to the ER (emergency room ). He was supposed to have it changed out at his follow up, which is not until Wednesday. Nurse was unable to obtain any orders as to what to do with the wound. The ER suggested that he come back there[sic] and they could look at the wound and give new orders. Patient sent back to the ER of the hospital where he had his surgery done. Rounding team notified. On 2/23/25 at 2:41 AM, a Progress Note is written by LPN R (Licensed Practical Nurse) that states, in part: . Wound vac in place but has ceased to function. Per the therapy unit patient guide, the unit was set to function for 14 days and then turn off. The therapy life indicator on the equipment states therapy has ended and will shut off. Resident to see his surgeon on Weds (Wednesday) 2/26. Dressing left in place to contain any drainage and prevent MRSA from spreading. Will ask am (day shift) staff to contact MD (Medical Doctor) for instructions regarding earlier appointment or intermittent dressing change orders. Resident aware and states his understanding . On 2/23/25 at 9:07 AM, a Progress Note is written by RN L. This note indicates a respiratory evaluation was completed including lung sounds. Nothing is noted regarding R237's wound vac. On 2/23/25 at 4:19 PM, a Progress Note is written by LPN O that states: Sent to ER. On 2/23/25 at 5:39 PM, a Progress Note is written by LPN O that states, in part: Wound vac was not functioning when arrived on shift. [MD Name] the on-call for neurosurgeon that placed the wound vac was contacted and advised to reach out to infectious disease because he was not comfortable advising as he does not often use wound vacuums. Infectious disease contacted and stated that since they did not place the wound vac nor write the order not to change until f/u (follow up) appt (appointment) they would not advise what to do. Called on-call neurosurgeon back and was transferred to the ED (emergency department) department instead. They were unable to recommend what action to take on a wound they were unable to assess. Recommend sending to their ED so they could handle the wound today and he would be able to see [MD Name] tomorrow. Contacted on-call for [MD Name] and was also advised to send to ER by NP Q. Contacted [Ambulance Service Name] for non-emergent transport to [Hospital Name] in [Hospital Location]. Res (resident) left facility at 1550 (3:50 PM) via stretcher transport through [Ambulance Service Name] . On 2/23/25 at 9:46 PM, a Progress Note is written by LPN O that states: Spoke we ER RN [RN Name] for report. Notes from previous stay from wound care gave instruction for wound care treatment. ER completed treatment and sending detailed orders with discharge paperwork. Advised to complete on[sic] Tuesday then follow [MD Name]'s orders after Wednesday appt. Res will be returning to the facility. Surveyor reviewed a document titled, After Visit Summary, dated 2/23/25, indicated to be from R237's emergency room visit. The document states, in part: . Instructions: Wound VAC has been removed. Regular cleansing with [Brand Name] solution and [Brand Name] dressing as needed. Follow-up as scheduled with neurosurgery on Wednesday. Copied from wound care note on February 10, 2025: If wound VAC fails and not able to maintain suction or integrity, then VAC dressing can be removed; Wound can be cleaned with [Brand Name] and gauze. Dried. [Brand Name] dressing to be applied. Surveyor reviewed the manufacturer's guide for R237's wound vac titled, 125 Therapy Unit Patient Guide. This document provides detailed troubleshooting instructions including what to do for excessive bleeding, if there is a full canister, if there are signs and symptoms of infection, and if there are signs and symptoms of an allergic reaction. The document also provides information on daily activity, sleeping, showering and bathing, and cleaning the device. On 2/26/25 at 7:55 AM, Surveyor interviewed LPN F. Surveyor asked LPN F if she has received any recent training regarding wound vacs. LPN F indicated that she has not received any training on wound vacs recently. Surveyor asked LPN F if she has any experience with wound vacs. LPN F indicates she does. Surveyor asked LPN F if there is usually a back-up plan, in physician orders or in the care plan, in case the device fails. LPN F indicates, yes it should come with orders and phone number to call in case it malfunctions. Surveyor asked LPN F what are the things you need to do to care for someone with a wound vac. LPN F indicates you need to check that they are set appropriate and that suction remains at the ordered level. Surveyor asked LPN F if a resident has a wound vac, should it be on the care plan. LPN F states, yes. On 2/26/25 at 7:59 AM, Surveyor interviewed LPN O. Surveyor asked LPN O if she has received any recent training regarding wound vacs. LPN O indicated that she has not received any training on wound vacs recently. Surveyor asked LPN O if she has any experience with wound vacs. LPN O indicates that she is an agency nurse and that most facilities have a wound nurse that cares for residents with wound vacs. Surveyor asked LPN O if there is usually a back-up plan, in physician orders or in the care plan, in case the device fails. LPN O also indicates she has not seen a lot of wound vacs in general, but that wound make sense. Surveyor asked LPN O what are the things you need to do to care for someone with a wound vac. LPN O indicates you just need to make sure they are functional and alert the RN if they are not. Surveyor asked LPN O if a resident has a wound vac, should it be on the care plan. LPN O states, yes. Surveyor asked LPN O if she was on shift on 2/23/25 when R237's wound vac malfunctioned. LPN O indicated that she was. Surveyor asked LPN O to describe what happened. LPN O describes what happened in the same way her progress note details. Surveyor asked LPN O what the device looked like when she assessed it. LPN O indicated all the lights were off, she didn't know if it just needed to be charged, attempted to turn the device back on but was unsuccessful, and that she has never seen a device like this before. Surveyor asked LPN O if she requested an RN to come to the room to assess the patient. LPN O indicated she did and RN L responded to R237's room. On 2/26/25 at 8:40 AM, Surveyor interviewed RN L. Surveyor asked RN L if she has received any recent training regarding wound vacs. RN L indicated that she has had wound vac training and estimates this training occurred around 6 months ago. Surveyor asked RN L if she has any experience with wound vacs. RN L states, yes. Surveyor asked RN L if there is usually a back-up plan, in physician orders or in the care plan, in case the device fails. RN L indicates the facility follows the doctor's directions and that there should be orders for changing dressings and if the device malfunctions, who we need to call to troubleshoot the problem. Surveyor asked RN L what are the things you need to do to care for someone with a wound vac. RN L indicates dressing changes usually occur around three times a week and sometimes you need to troubleshoot them if a seal may be broken or if the cannister needs to be changed. Surveyor asked RN L if a resident has a wound vac, should it be on the care plan. RN L states yes, and that she did care plan R237's wound vac. Surveyor asked RN L if she was on shift on 2/23/25 when R237's device malfunctioned. RN L indicates she was on shift. Surveyor asked RN L to describe what happened. RN L indicated she was very frustrated by the lack of cooperation with hospital on-call physicians. RN L indicates the wound vac shut off, indicating that therapy had ended, and the device would not turn back on. RN L indicates she requested a CNA (Certified Nursing Assistant) to assist with rolling the resident to assess wound. Surveyor asked RN L what the dressing looked like on the patient's back. RN L indicates the dressing was still sealed and intact, and that she did not observe any signs of erythema (redness) or drainage coming from the dressing. Surveyor asked RN L if she removed the dressing to assess the wound at any point. RN L indicates she did not. RN L indicated that the manufacturers guidelines book advised to call a provider, so she attempted to call the on-call physicians as described earlier without orders being provided. RN L indicates the facility's provider then provided orders for R237 to be sent to the emergency room at the hospital where he originally had his surgery. On 2/26/25 at 9:06 AM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B if there has been any recent training provided on wound vacs. DON B indicates she has shown some nurses how to change the dressings. DON B also indicates she does informal training and that her practice is to ensure staff are comfortable caring for a resident with a wound vac. DON B also indicates staff know they can call her if they need assistance. Surveyor asked DON B if she has any previous experience with wound vacs. DON B states, yes. Surveyor asked DON B do resident's with wound vacs usually have a back up plan in the physicians orders or care plan. DON B indicates staff typically call the on call so that they can provide orders until a resolution can be made, but typically their in-house provider should be contacted. Surveyor asked DON B if a resident has a wound vac, should it be on the care plan. DON B states, yes. Surveyor what R237's care plan says about his wound vac. DON B reviewed R237's care plan and indicated she only found the intervention listed previously. Surveyor asked DON B if the care plan should have information on who to call for new orders. DON B indicates the facility would not typically put a specific phone number there, but that the intervention should say provider and not MD and list which provider to call for new orders. Surveyor asked DON B how she monitors staff to ensure they are implementing care planned interventions. DON B indicates she does not know how to answer this question, but that she checks in with staff and completes audits. Surveyor asked DON B if information on how to troubleshoot the device should be listed on the care plan. DON B indicates not in particular, and the hospital documentation states we should call the wound care clinic. Surveyor asked DON B if calling the wound care clinic should be a part of the care plan. DON B indicates she is not sure but that usually they would not have that as part of the care plan but it usually is put int the special instructions section of the dashboard of the electronic medical record. Surveyor asked DON B if those special instructions were included on the dashboard for R237. DON B indicates they were not.

Based on interview and record review, the facility did not ensure that residents who are continent of bladder and bowel, on admission, receive services and assistance to maintain continence, unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 1 resident's (R25) reviewed for bowel and bladder. The facility did not develop a toileting plan for R25 after they assessed and concluded that R25 would be a candidate for retraining. This is evidenced by: The facility's policy and procedure entitled Urinary Incontinence - Clinical Protocol/Guidelines, with an effective date of 10/2024, states, in part: Assessment and Recognition 1. As part of the initial assessment, the nursing staff will attempt to identify individuals with impaired urinary continence, i.e., reduced ability to maintain urine in a socially appropriate manner .3. For incontinent individuals, the nursing staff will identify, and document circumstances related to the incontinence; for example, frequency, nocturia, dysuria, or relationship to coughing or sneezing .Treatment/Management .2. Assess for environmental interventions and assistive devices (e.g., grab bars, raised toilet seats, bedside commodes, urinals, bed rails, restraints, and/or walkers) that facilitate toileting. 3. As appropriate, based on assessment of the category and causes of incontinence, provide a scheduled toileting, prompted voiding, or other interventions to try to improve the individuals' continence status . R25 was admitted to the facility on [DATE], with diagnoses that include, in part: polyosteoarthritis, atherosclerotic heart disease, type 2 diabetes, hypertension, and muscle weakness (generalized). R25's most recent Quarterly Minimum Data Set (MDS), with Assessment Reference Date (ARD) of 2/12/25 states that R25 has a Brief Interview for Mental Status (BIMS) of 15 out of 15, indicating that R25 is cognitively intact. Section GG states R25 requires partial/moderate assistance for toilet transfers and requires partial/moderate assistance for walking 10 feet. Section H states R25 does not use any bladder and bowel appliances, has not had a trial of toileting program attempted since admission to the facility, and that R25 is frequently incontinent, which is defined as 7 or more episodes of urinary incontinence, but a least one episode of continent voiding). R25's Physician Orders state, in part: Furosemide Oral Tablet 20 MG (Furosemide) Give 1 tablet by mouth one time a day for edema (swelling). Order status: Active. Start Date: 5/7/24. (Of note: Furosemide is a diuretic and often causes the need to urinate more frequently) R25's evaluation titled, Bladder Incontinence Evaluation- V2, indicates it is unknown if R25's incontinence has a recent onset, R25 currently uses disposable continence products, specifically adult briefs at night only and adult underwear during the day only (Pull Ups). This document also indicates R25 is taking a diuretic, has decreased manual dexterity, requires physical assistance to access commode/urinal, and has decreased muscle strength in his lower extremities. Environmental factors identified include distance to toilet and requires grab bars for support. Type of incontinence is identified as Functional (Normal function affected by environment or disease). A question that states, Irreversible but there is a potential for continence to be maintained or improved by reducing incontinent episodes through a bladder program is marked yes. The Approaches/Plan section has Habit Training/Scheduled Toileting and Incontinence Products/Garments both checked. R25's Comprehensive Care Plan, states, in part: Focus: [Resident Name] is incontinent at times of urine. Date initiated: 5/9/24. Interventions: BRIEF USE: [Resident Name] uses disposable briefs. Change daily and PRN (as needed). Date initiated: 5/9/24. Ensure unobstructed path to the bathroom. Date initiated: 5/9/24. INCONTINENT: Wash, rinse, and dry perineum. Change clothing PRN after incontinent episodes. Date initiated: 5/9/24. Monitor/document s/sx (signs and symptoms) of UTI (urinary tract infection). Date initiated: 5/9/24. (Of note: R25's Comprehensive Care Plan does not note any type of habit training or scheduled toileting program). On 2/26/25 at 4:53 PM, Surveyor interviewed RN L (Registered Nurse). Surveyor asked RN L who completes the resident comprehensive care plans. RN L indicates that DON B (Director of Nursing) was, but recently RN L has taken over this responsibility. Surveyor asked RN L who is responsible for setting up the bladder and bowel programs. RN L indicates all she does is set up the care plan and she does not do anything with the bowel and bladder program or management diaries. On 2/26/25 at 5:06 PM, Surveyor interviewed DON B (Director of Nursing). Surveyor asked DON B who is responsible for completing the resident comprehensive care plans. DON B indicates it is a shared responsibility between herself and RN L; however, RN L completes the bulk of initiating care plans and each specialty, such as dietary or therapy, works on their own section. Surveyor asked DON B who is responsible for completing bladder and bowel diaries or managing the bowel and bladder program. DON B indicates she is unsure if the facility has been doing formal bladder and bowel diaries. Surveyor advised DON B that R25's Bladder Incontinence Evaluation indicates the facility had a plan to conduct habit training or scheduled toileting to improve or maintain R25's urinary continence. Surveyor asked DON B if those interventions should have been conducted. DON B indicates that if the facility said they were going to do those interventions, they should have done them and documented it.

Based on observation, interview, and record review, the facility did not ensure nursing staff followed professional standards of practice when flushing a peripherally inserted central catheter (PICC) for 1 of 1 residents reviewed (R237). Staff did not check blood return prior to flushing R237's PICC. Evidenced By: The Facility follows their Pharmacies Policy and Procedure entitled Central Vascular Access Device (CVAD) Flushing and Locking dated 6/1/24, it documents the following in part: .Considerations: 1. Central vascular access devices (CVADs) include: 1.1 Peripherally inserted central catheter (PICC) .4. Flushing/locking is performed to ensure and maintain catheter patency and to prevent the mixing of incompatible medications/solutions. 5. Needless connectors require vigorous cleansing with alcohol prior to accessing to reduce the risk of catheter related bloodstream infection .Guidance .5. Catheter patency must be verified prior to each medication administration. To assess patency, aspirate the catheter to obtain positive blood return. The aspirated blood should be the color and consistency of whole blood .Procedure: 1. Verify prescriber order. 2. Identify patient using appropriate identifiers. 3. Explain procedure to patient/significant other. 4. Perform hand hygiene. 5. Assemble equipment and supplies on clean work surface. 6. [NAME] gloves. 7. Vigorously cleanse needleless connector with alcohol. Allow to air dry .9. Attach syringe filled with prescribed flushing agent to needleless connector. Aspirate the catheter to obtain positive blood return to verify vascular access patency. 10. Flush while observing for signs and symptoms of complication/infiltration. 11. Disconnect syringe .12. Dispose of used supplies per facility policy. 13. Remove gloves. 14. Perform hand hygiene. 15. Documentation in the medical record . R237 is a recent short-term admission to the facility. R237 has the following diagnoses: sepsis due to methicillin resistant staphylococcus aureus, infection following procedure deep incisional surgical site, type 2 diabetes mellitus, and morbid obesity due to excess calories. R237's Progress Note dated 2/15/24 at 21:50 (9:51 PM) documents: PICC flushed with NS and blood return noted. Wound vac and dressing in place. Ice for R (right) hand. On 2/26/25 at 6:56 AM, Surveyor observed RN/MDS L (Registered Nurse/Minimum Data Set) perform R237's PICC line medication initiation. RN/MDS L performed hand hygiene, donned appropriate personal protective equipment (PPE), knocked on R237's door, announced herself and Surveyor, explained what she was there to do, and set up her supplies. RN/MDS L hung IV (intravenous- into or within a vein) medication bag on the IV pole, primed the IV tubing, and removed air bubbles. RN/MDS L cleaned the hub (end) of the PICC line with alcohol, removed NS (normal saline- solution) syringe from package and removed cap, attached NS syringe to hub of PICC line, she unclamped PICC line port and began flushing line with a pulsating (push/stop) motion until syringe was empty. RN/MDS L then took the end of the IV medication bag tubing and removed cap, she cleaned the PICC line hub with alcohol again, attached the IV medication bag tubing to the PICC line hub, set the pump to the correct setting, unclamped IV tubing and PICC line clamps, and monitored for medication to run appropriately. Once that was noted, RN/MDS L doffed PPE, performed hand hygiene, and exited room. It is important to note that RN/MDS L never aspirated (pulled back) to obtain blood return prior to administering medication per their policy and procedure. On 2/26/25 at 4:26 PM, Surveyor interviewed RN/MDS L. Surveyor asked RN/MDS L to explain the flushing protocol for a PICC line, RN/MDS L said complete hand hygiene, alcohol cap, attach syringe, flush line in pulsating motion, remove syringe, and re-apply clamp. Surveyor asked RN/MDS L should blood be aspirated during flush prior to medication administration, RN/MDS L stated I was never taught that, I would for a peripheral line, I was not taught that with PICC line, not even when administering chemotherapy medication. Surveyor asked RN/MDS L if she had had any IV/PICC line training or education here at this facility, RN/MDS L replied skill checks annually but I just started in June, I had one of the nurses go through this with me so I would know how. On 2/26/25 at 10:09 AM, Surveyor interviewed RN M. Surveyor asked RN M to explain the flushing protocol for a PICC line, RN M stated, Clean the hub for 30 seconds with alcohol, attach syringe, unclamp line, push a little NS in, pull back for blood return, finish flush of NS, detach the syringe, and re-clamp line. Surveyor asked RN M how she knew to pull back for blood return, RN M stated that's the way she was taught in the hospital. Surveyor asked RN M if she had, had any IV/PICC line training or education here at this facility, RN M stated, No not since I've been here. On 2/26/25 at 11:51 AM, Surveyor interviewed RN D. Surveyor asked RN D to explain the flushing protocol for a PICC line, RN D replied take the cap off, clean the hub with alcohol, unclamp. flush with NS, re-clamp, and put the cap back on. Surveyor asked RN D if she would aspirate blood, RN D said I don't. Surveyor asked RN D if she had had any IV/PICC line training or education here at this facility, RN D said the pharmacy has come out in the past but not recently. Surveyor asked RN D if LPN's (Licensed Practical Nurses) do IV therapy, RN D said no they do not. On 2/26/25 at 4:55 PM, Surveyor interviewed DON/IP B (Director of Nursing/Infection Preventionist). Surveyor asked DON/IP B what standard of practice you use for PICC line flushing and maintenance, DON/IP B said the pharmacy guideline. Surveyor asked DON/IP B how you expect a PICC line to be flushed, DON/IP B explained they'd clean the hub with alcohol, flush out air bubbles from syringe, attach to needless connector, flush in pulsation motion until gone, and disconnect. Surveyor asked DON/IP B would you expect blood to be aspirated prior to medication administration, DON/IP B stated, No. On 2/26/25 at 5:44 PM, Surveyor interviewed DON/IP B. Surveyor asked DON/IP B how you ensure nurses are competent when using a PICC line, DON/IP B said there is a list of tasks that need to be signed off within 30 days of hire. Surveyor asked DON/IP B who signs off the nurses, DON/IP B said DON/IP B. Surveyor asked DON/IP B how frequently competency is reviewed, DON/IP B said annually. Surveyor asked DON/IP B how competency is completed for PICC line care, DON/IP B replied I watch them do the task. Surveyor asked DON/IP B if that is documented, DON/IP B stated no. Surveyor asked DON/IP B would you expect staff to be able to perform PICC line skills competently, DON/IP B stated yes. According to <https://www.ncbi.nlm.nih.gov/books/NBK594495/> Before flushing the lumen with 0.9% sodium chloride, aspiration of blood should be attempted to ensure patency. The volume of fluid used for flushing should be twice the volume of the lumen. RN/MDS L was observed not following the policy and procedure for IV medications and does not have a competency check for administering IV medication.

Based on interview and record review, the facility did not ensure hospice collaboration and communication processes were established to ensure continuity of care between hospice and the facility for 1 of 1 resident (R7) reviewed for hospice. R7's current hospice plan of care and visit notes were not available to facility staff. The facility did not designate a staff member to coordinate the plan of care with the hospice provider. This is evidenced by: The facility's Hospice Program policy, dated 10/2024, states, in part: .7. Identify a member of the IDT (interdisciplinary team) who is responsible for working with the hospice representative.This person's responsibilities include: .d. Ensuring the appropriate documents are readily available.If the hospice does not document in PCC (Point Click Care-the facility electronic health record), community may include selecting one personal to scan and upload hospice documents to the resident's electronic medical record no more than 5 days after documents are received as outlined below, to include: i. most recent hospice plan of care.viii. Visit notes from all hospice disciplines, nurse, chaplain, social services, and volunteer.9. The community retains the ultimate responsibility for the care plan. Coordinate the plan of care with the hospice provider, community staff and resident/family. 10. To promote continuity of care, collaborate with the hospice, nursing home and resident/representative on a coordinated care plan noted in the medical record . 14. Designate a member of the community staff to coordinate the plan of care with the hospice provider, specifically to ensure coordination, continuity of care and to resolve differences. Each provider should know how to review the other's care plan. R7 was admitted to the facility on [DATE] and has diagnoses that include, in part: encounter for palliative care (care specializing in managing symptoms and improving quality of life); dementia with agitation (a condition characterized by impairment of brain function, such as memory loss and impaired judgement along with a state of restlessness, anxiety, or distress); diastolic heart failure (a condition where the heart muscle is unable to function properly resulting in reduced blood flow to the body). R7's physician orders include, in part: (provider name) Hospice services related to terminal prognosis. Order date: 3/15/24. On 2/25/25 at 4:08 PM, Surveyor interviewed LPN F (Licensed Practical Nurse) and asked how the facility communicates with hospice. LPN F stated resident's receiving hospice services have a hospice binder for information to be kept. LPN F stated that there is not a facility contact person for hospice; all the nurses communicate with hospice as needed. On 2/26/25, at 9:00 AM, Surveyor asked LPN F for R7's hospice plan of care. LPN F stated she was unable to locate R7's binder in the nurse's station cupboard and stated that each hospice patient is handled differently. On 2/26/25 at 9:02 AM, Surveyor asked RN D (Registered Nurse) for R7's hospice plan of care. RN D stated that RN D was unable to locate R7's binder in the nurse's station cupboard. Surveyor asked RN D how the facility gets information from hospice. RN D stated R7's provider faxes new orders to the facility. Surveyor asked how the facility receives visit notes. RN D stated R7's hospice provider doesn't necessarily send visit notes to the facility. Surveyor asked if there is a facility contact person for hospice coordination. RN D said there is no one person; all the nurses contact hospice as needed. RN D requested assist from DON B (Director of Nursing) with locating the binder. DON B was able to locate the binder in the nurse's station cupboard and provide to surveyor. Binder included information for multiple residents receiving services from (provider name) hospice. R7's information included a plan of care for benefit period 11/9/24 through 1/7/25 and a skilled nursing visit summary dated 12/17/24. On 2/26/25 at 9:33 AM, Surveyor interviewed RN D and asked how often there is facility collaboration with hospice. RN D stated one to two times weekly; more as needed. Surveyor asked where this is documented. RN D stated there is mostly verbal discussion that is not documented. Surveyor asked if the resident's most recent hospice documentation should be in the hospice binder. RN D stated yes. Surveyor asked RN D to review the information in the hospice binder for R7. RN D stated that the date of the most recent plan of care was 12/19/24 and the date of the most recent visit note was 12/17/24. Surveyor asked if there should be a current plan of care and visit notes for staff to reference. RN D stated yes, there is nothing here from 2025. Surveyor asked how the facility ensures that the facility plan of care and the hospice plan of care match. RN D stated if we don't have a current plan of care, we can't. On 2/26/25 at 10:21 AM, Surveyor interviewed DON B (Director of Nursing) and asked if there is a facility staff member who coordinates hospice. DON B stated their nurses handle communication with hospice on their own; there is no coordinator in house. Surveyor asked if there should be a current hospice plan of care and visit notes in the hospice binder for staff to reference. DON B stated yes.

Based on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. This has the potential to affect all 31 residents. Surveyor observed milk left out for the duration of lunch service without any way to keep it cold and the milk temperature was 58 degrees. Surveyor observed DM G (Dietary Manager) not follow manufacturer's recommendations for use while utilizing the 3-compartment sink. Surveyor observed open food to have been removed from the original container with no expiration date and no open date. Surveyor observed a dented can in circulation. Surveyor observed the facility's mixer and meat slicer to be stored unclean. Evidenced by: Example: milk Facility policy, entitled Food Preparation and Service, dated 10/2023, includes in part .refrigerated foods must be stored at or below 41 degrees Fahrenheit unless otherwise specified by law. Food items and snacks kept on the nursing units must be maintained as indicated: All food items to be kept below 41 degrees Fahrenheit must be placed in the refrigerator located at the nurses' station and labeled with a use by date. The danger zone for food temperatures is between 41 degrees and 135 degrees Fahrenheit. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese . On 3/4/24 from 11:50 AM to 12:21 PM, Surveyor observed a gallon of milk placed on a beverage cart in the dining room. DA H (Dietary Aide) returned the milk to the kitchen and was going to put it in the refrigerator. Surveyor requested that DA H complete a temperature check of the milk, resulting in a reading of 58 degrees Fahrenheit. On 3/4/24 at 12:21 PM, DA H indicated she would not have thought to complete a temperature check on the milk and would have returned it to the refrigerator for later use. DA H also indicated the milk should not have been left out that long and should be stored at or below 41 degrees Fahrenheit. On 3/7/24 at 11:20 AM, DM G indicated milk should not be left out and should be kept at a temperature at or below 41 degrees Fahrenheit. DM G indicated staff will now put the milk in an ice bath while it is out of the refrigerator. On 3/7/24 at 11:31 AM, NHA A indicated milk should be stored at or below 41 degrees Fahrenheit and the facility would be using a tub of ice to keep milk in throughout the meal service. Example: three compartment sink Manufacturer's recommendations for use of 3 compartment sink, entitled Pot and Pan Wash Procedure, dated 2018, states in part .Submerge in sanitizer sink for one minute. On 3/6/24 at 9:59 AM, Surveyor observed the manual dishwashing process. During observation Surveyor noted DM G (Dietary Manager) dipping dishes in and out of each sink compartment. On 3/6/24 at 10:16 AM, DM G stated, I'm just making sure it's fully submerged and indicated she was unaware that she was not following manufacturer's recommendations of leaving the dishes submerged for at least one minute. On 3/7/24 at 11:20 AM, DM G indicated dishes washed in the 3-compartment sink should be fully submerge in the sanitizer sink for at least a minute. Example: undated food Facility policy, entitled Food Safety Requirements dated 10/2023, includes in part .All foods stored in the refrigerator or freezer will be covered, labeled and dated. On 3/4/24 at 8:54 AM, during initial tour of the facility's kitchen, Surveyor observed breadsticks, tator tots, and hashbrowns in the facility's freezer to be removed from the original container and without the manufacturer's expiration date and without an open date or use by date. Surveyor also observed the food to be exposed as the plastic around it was not closed properly. On 3/4/24 at 8:54 AM, DM G indicated the breadsticks, tator tots, and hashbrowns should be marked with a use by date and/or the manufacture's expiration date. Example: dented can Facility policy, entitled Food Safety Requirements dated 10/2023, includes in part .Dented cans will be identified and removed from regular dry food storage. The dented cans should be placed in a specific labeled area of the storage room awaiting pick up from the appropriate vendor. On 3/4/24 at 8:57 AM, during initial tour of the facility's kitchen, Surveyor observed a dented can in circulation on the shelf in the dry storage area. On 3/4/24 at 8:57 AM, DM G indicated that dented cans are usually thrown away and the can should have been removed from circulation. Example: unclean equipment Facility policy, entitled Sanitation dated 10/2023, includes in part .Utensils, counters, shelves and equipment shall be kept clean, maintained in good repair . Equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water and/or chemical sanitizing solutions. On 3/4/24 at 8:54 AM, during initial tour of the facility's kitchen Surveyor observed a meat slicer and a mixer that were stored covered by a cloth. When the cloth was removed, Surveyor and DM G observed food particles on both pieces of equipment. On 3/7/24 at 11:20 AM, DM G indicated the equipment is unclean and it should have been cleaned thoroughly before being covered and stored.

Based on observation, interview, and record review, the facility did not ensure that residents who are unable to carry out Activities of Daily Living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 2 residents (R19) out of a total sample of 15. R19 had facial hair and requires assistance with shaving. This is evidenced by: R19 was admitted to the facility on [DATE] with diagnoses that include, in part: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side (Paralysis and Weakness following a Stroke), Other Reduced Mobility, Unspecified Lack of Coordination, and Weakness. R19's quarterly Minimum Data Set (MDS) with a target date of 1/10/24 indicates in part: Section C: A Brief Interview for Mental Status (BIMS) of 5, indicating R19 has a severe cognitive impairment. Section GG: Indicates in part, R19 requires substantial/maximal assistance - Helper does more than half the effort, for personal hygiene. R19's care plan indicates, in part: An ADL Self-Care Performance Deficit initiated on 1/13/20. Interventions include, in part, Bathing Preference AM shower on Monday. R19 has impaired cognitive function/impaired thought processes related to cognitive defects initiated on 1/14/21. Interventions indicate R19 has an activated Power of Attorney for Health Care (POAHC). Of note, information regarding R19 wanting to be clean shaven was added to the care plan as of 3/6/24 after Surveyor brought the concern to the facility. On 3/6/24, Surveyor reviewed the last two weeks of R19's shower record that indicated he had been given showers on 2/26/24 and 3/4/24. On 3/5/24 at 9:01 AM, Surveyor observed R19 in the dining room and noted facial hair was present. On 3/6/24 at 7:17 AM, Surveyor observed R19 in his room, dressed, in his wheelchair and noted facial hair was present. On 3/4/24 at 11:27 AM, Surveyor contacted R19's POAHC C who expressed a concern regarding R19 not being shaved. POAHC C indicated R19 sometimes isn't shaved for 3 days. POAHC C indicated this bothers her and she feels it would bother R19 as he used to shave every day. On 3/6/24 at 10:19 AM, Surveyor interviewed POAHC C at the facility while she was there visiting R19. POAHC C indicated that she has spoken to staff at the facility regarding her concern about R19 not being shaved. POAHC C indicated the last time she recalled reporting this was at R19's last care conference in January. POAHC C indicated that she has told staff two or three times that she feels like he looks homeless. POAHC C indicated they did not give her any expectations on how often he should be shaved but that she believes he should be shaved every day as that is what he did at home. On 3/6/24 at 7:30 AM, Surveyor interviewed CNA D (Certified Nursing Assistant) who indicated that male residents are shaved on their shower days. CNA D indicated she did not know why this was and that this was how she was trained. On 3/6/24 at 7:45 AM, Surveyor interviewed CNA E who indicated that male residents are shaved on their shower day. On 3/6/24 at 11:04 AM, Surveyor interviewed DON B (Director of Nursing) who indicated if a male resident is unable to let staff know when he would like to be shaved then the facility would go by what the POA requests. DON B indicated she was not aware that staff was only shaving male residents on shower days as some men grow hair quicker than that and by the time they get to a week it would be too long. DON B indicated that if a resident is someone who would like to be clean shaved every day it would be in their care plan otherwise it would be as needed. On 3/7/24 at 10:23 AM, Surveyor interviewed DON B who indicated the facility does not have a policy on how often residents should be shaved.

Based on interview and record review, the facility did not ensure that, based on the comprehensive assessment of a resident, the residents receive treatment and care in accordance with professional standards of practice. This had the potential to affect 1 out of 15 residents reviewed (R20). R20 had a fall. LPN F (Licensed Practical Nurse) moved R20 off of the floor with an obvious injury and without a thorough assessment by a Registered Nurse (RN). Evidenced by: Facility policy, entitled Assessing Falls and Their Causes Guideline, effective 9/2023, includes: . After a fall- If a resident . found on floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to head, neck, spine, and extremities. If there is evidence of a significant injury such as a fracture or bleeding, nursing staff will provide appropriate first aid . Once an assessment rules out significant injury, nursing staff will help resident to a comfortable sitting, lying, or standing position . R20 admitted on [DATE] with diagnoses, including: repeated falls, unsteadiness on feet, weakness, lack of coordination, cognitive communication, and abnormal posture. R20's Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 9/26/23 indicates R20's cognition is intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R20's Medical Record includes: R20's Comprehensive Care Plan, initiated 6/30/21, includes: . R20 is at risk for falls related to history of falls, impaired balance, incontinence, limited mobility . Goal: R20 will be free from serious injury .Anticipate and meet needs as able. Be sure call light is within reach and respond promptly to requests for assistance . Ensure a safe environment with adequate lighting, reachable call light, and personal items within reach . PT to evaluate and treat. R20's Nurse Note, dated 12/6/23, includes: Writer alerted to resident fall by CNA (Certified Nursing Assistant). Writer noted resident face down at foot of the bed with legs extended. Resident was responsive per baseline to writer's questions. Resident denied pain to neck and back. Writer and other CNA's assisted resident to supine position. Resident complained of pain in right knee rating 10 out of 10 pain. Resident reported reaching for something on side table when they slipped out of chair. Resident assisted to bed via hoyer lift [full body lift]. Ice pack applied to right knee for immediate pain intervention. Resident agreed to be seen at hospital for further evaluation. Transported to hospital at 9:00 PM via ambulance. R20's Fall Report, dated 12/6/23, includes: incident description: Writer alerted to resident fall by CNA (Certified Nursing Assistant). Writer noted resident face down at foot of the bed with legs extended. Resident was responsive per baseline to writer's questions. Resident denied pain to neck and back. Writer and other CNA's assisted resident to supine position. Resident complained of pain in right knee rating 10 out of 10 pain. Resident reported reaching for something on side table when they slipped out of chair. Resident assisted to bed via hoyer lift. Ice pack applied to right knee for immediate pain intervention. Resident agreed to be seen at hospital for further evaluation. Transported to hospital at 9:00 PM via ambulance. DON B (Director of Nursing), emergency contact, and MD notified via fax .immediate action: Ice pack for pain . transported to hospital for further eval . level of pain:10 out of 10 . Note text: resident observed on floor in room between chair and bed. Resident stated she was attempting to reach item from table, slid out of chair. Pain 10 out of 10 in knee per resident report. Resident sent to hospital emergency room for evaluation. Resident transferred from hospital to another hospital due to right hip fracture. Per staff interviews root cause likely silky pajamas and reaching. New intervention replace pajamas with cotton . less slippery material if resident allows . use dycem in wheelchair . LPN F's written statement: . noted face down on floor. Assessed for injuries. Complained of right knee pain. Assisted up with hoyer. Send out via ambulance due to right knee pain, blood in sclera and redness above brow. CNA N written statement: Resident's call light went on at 9:00 PM. I walked in room and saw her face down on the floor. I called for help and to get the nurse. While waiting I put a blanket by her head and took her glasses off. Nurse came. We got her on her back to check vitals and skin. Resident complained of 10 out of 10 pain to her right knee. After vitals we used the hoyer to get her in bed . R20's Post Fall Assessment, dated 12/6/23, includes: blood pressure- 146/89 . is there a widening pulse pressure? No . respirations at time of eval- 16 . Are the respirations increased from the resident's baseline? No . Are respirations shallow? No. Pulse- 108 . Has pulse increased from baseline? Yes . Resident cognitively impaired? No. Ask the resident to move all extremities: (No other notes regarding the outcome of this action are included.) Additional comments: complained of right knee pain . (It is important to note this assessment does not include what happened when resident was asked to move all extremities. It does not mention if resident had any shortening of extremities or any internal or external rotation concerns. It does not capture how much pain the resident is reporting.) R20's Hospital Note (from the second hospital), dated 12/12/23, includes: Admission 12/7/23 . Discharge 12/12/23 . diagnoses: status post hip surgery-primary, closed fracture of neck of right femur, initial encounter . Date of procedure: 12/7/23 pre-op diagnosis: right femoral neck fracture . Procedure: right hip percutaneous screw fixation . Indications for procedure: (R20) . sustained a valgus impacted left femoral neck fracture. In light of this injury, I did recommend that she undergo percutaneous screw fixation . Operative findings: valgus impacted femoral neck fracture . On 3/5/24 at 4:25 PM during an interview, LPN F indicated on 12/6/23 she was the charge nurse and there was not an RN working. LPN F indicated she stepped outside to take a break when a CNA came outside to get her because R20 was on the floor. LPN F came back into the building and observed R20 to be face down on the floor, between the recliner and her bed. LPN F indicated R20 could answer questions appropriately and she could complete range of motion with her shoulders. LPN F indicated she assisted R20 to a supine position on her back and checked her skin for immediate injuries. LPN F indicated she slowly sat R20 upright and she began to express pain in her knee. LPN F indicated she knew R20's pain was significant due to her voicing it and her facial grimacing with any movement. LPN F indicated she could visibly see R20's knee was swelling and she thought her knee was dislocated or broken. LPN F stated, The injury looked significant. LPN F then instructed one CNA to go get an ice pack and one to retrieve the hoyer lift. LPN F indicated two CNAs and herself used the hoyer lift to raise R20 onto her bed. LPN F indicated she did not consult with an RN or an MD before moving R20. When asked if LPN F should have moved R20 when R20 voiced pain and she could see signs of an injury. LPN F stated, Probably not. LPN F indicated she called the ambulance service to take her out and then texted DON B regarding the situation. On 3/5/24 at 4:43 PM, DON B indicated when a resident falls she expects the charge nurse would do a complete assessment consisting of vitals, neuro checks, skin check, rotation of extremities, and a check for deformities. Surveyor asked DON B for this assessment after R20's 12/6/23 fall. DON B indicated the facility did have some documentation of vitals and pain but did not have the rest of the pieces required to meet her definition of full assessment. DON B indicated assessments are out of the scope of practice for LPNs, but they can gather the data. DON B indicated LPN F did not consult with her, another RN, or an MD before transferring R20 to her bed using a hoyer lift. DON B indicated if a resident is complaining of pain and a visible injury is noted, staff should not transfer the resident because it could cause more injury. DON B indicated LPN F should have called her, NHA A (Nursing Home Administrator) or the on-call MD to consult with, prior to moving the resident. On 3/6/24 at 9:52 AM, NHA A and DON B indicated they have been working on fall reduction and response in Quality Assurance Improvement Process, but the nurses have not all completed the education piece. NHA A and DON B indicated LPNs can gather data, but they need to consult with an RN or MD with the collected data. DON B indicated LPN F should not move a resident who is experiencing 10 out of 10 pain and that has visible signs of swelling of the knee. On 3/6/24 at 10:24 AM, CNA M indicated she was taking the laundry from all the halls when CNA N came out or R20's room instructing her to get LPN F. CNA M indicated she got the nurse and together went to R20's room. CNA M indicated as soon as LPN F and CNA N started to turn R20 over she was wincing and verbally expressing pain located in her knee. CNA M indicated R20 was not asking to be moved off of the floor. On 3/6/24 at 10:45 AM, CNA N indicated she found R20 on her right side lying on the floor, almost face down. CNA N indicated she could immediately see swelling and bruising to R20's face and she removed R20's. CNA N stated, I did not want to move her. She was contorted and I put a blanket down and I sat there and held her until LPN F got done with her skin and neuro checks. We slid the hoyer sling underneath her and got her in bed. She was not crying but you could tell she was in a lot of pain. She did not ask to get off the floor or into bed. She wasn't talking much. Surveyor asked how CNA N could tell R20 was in pain. CNA N stated, R20 was wincing in pain. Surveyor asked if there were any special measures taken to protect R20's knee during the transfer. CNA N indicated she did not recall. On 3/6/24 at 2:30 PM, CNA O indicated she came into R20's room and saw bruising and bruising/discoloration on R20's face and one foot was different than the other foot. CNA O indicated LPN F instructed staff to assist in getting R20 onto her bed and they did. Surveyor asked if there were any special measures taken to protect R20's foot during the transfer. CNA O indicated she was not sure, but generally one staff will guide the feet up as the hoyer lifts. LPN F did not gather all required information and did not consult an RN or MD prior to moving R20 after a fall with suspected injury and evidence of pain.