Every finding on record at Crimson Heights Health & Wellness

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his for 3 of 3 residents (Resident #1, Resident #2, Resident 5) reviewed for resident rights.The facility failed to ensure staff assisted Resident #1, Resident #2, Resident 5 by failing to answer call lights in a timely manner to provide assistance. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.The Findings include:Record review of Resident1's Face Sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease (air flow is restricted during breathing), Hypothyroidism (thyroid gland doesn't make enough hormone), Hyperlipidemia (plaque buildup in arteries), Schizophrenia (brain disorder), hypertension (blood flowed through the vessels with high force), Type 2 diabetes mellitus with hyperglycemia (Insulin resistant), Paraplegia (paralysis affecting the lower half of body).Record Review of Resident1's Care plan dated 3/6/2026 revealed the following:Problem: Resident1 requires assistance with ADLs (start dated 3/28/25 and edited 12/16/25)Goal: Resident1 will improve/maintain current ADL independence (start dated 3/28/25 and edited 12/16/25).Approach: Resident1 requires supervision x 1 with eating (8/19/25); assist resident as need with personal hygiene (3/28/25).Problem: Resident1 has a diagnosis of seizures and is at risk of injury (12/16/25)Goal: Resident1 will not injure self-secondary to seizure disorder (edited 12/16/25 and long-term goal target date 3/16/26).Approach: Keep call light within reach (3/28/25)Problem: Resident1 is at risk for falling r/t muscle weakness and impaired mobility, contractures (12/16/25).Goal: Resident1 will remain free from injury through the next 90 days (12/16/25).Resident was totally dependent on staff for all her ADLs and staff was to ensure the call light is within reach.Approach: Keep call light in reach at all times (3/28/25).In an interview on 3/5/26 at 10:15 am with Resident1 she stated it takes staff at least 30 minutes or more to answer call buttons. She stated on a few occasions she needed to be changed, and it took more than 30 minutes for her call light to be answered. She stated sitting in soiled diaper creates a feeling of helplessness. She stated she deals with depression and not being independent and having to depend on staff who let you down increases her level of depression. She stated the call light issues are on going and have been taken to the resident council for grievance.Record review of Resident 2's undated Face Sheet revealed an [AGE] year-old female who was originally admitted to the facility 11/9/25 and readmitted on [DATE] with a diagnoses of Chronic obstructive pulmonary disease with (acute) exacerbation (Admission), Immunodeficiency (your body's ability to fight diseases is reduced), Type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar causes nerve damage), Upper respiratory infection (bacteria illness affecting nose, throat, and sinuses), Anxiety disorder (uncontrollable fear), and Hypertensive heart disease with heart failure (chronic high blood pressure).Record review of Resident 2's baseline MDS dated [DATE] revealed a BIMS score of 12 (resident has moderate cognitive impairment). Resident 2 required supervision or touching assistance for all of her ADLs.Record Review of Resident #2's Care plan dated 2/12/26 revealed the following:Problem: Resident 2 is at risk for falling R/T COPD, impaired cognition and ambulatory status [02/24/2026]Goal: Resident 2 will remain free from injury through next 90 days [3/2/26]Approach: Keep call light in reach at all times [11/24/25]; Observe frequently and place in supervised area when out of bed [11/24/25]Problem: At risk for S&A of hyper/hypoglycemia (blood sugar drop) r/t diagnosis of diabetes mellitus [2/24/26]Goal: Blood sugar will remain within acceptable range set per MD orders [2/24/26Approach: Provide diabetic snacks between meals and at bedtime [11/10/25].In an interview on 3/5/26 at 9:30am with Resident 2 she stated she is on hospice. She stated she is supposed to get a snack in the evening due to her diabetes; however, when she pushes her call light it takes approximately 45 minutes or more to get answered. Sometimes the call is not answered. She stated that her not getting her evening snack makes her feel nauseated and sick to the stomach.Record Review of Resident 5 undated face sheet revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis of Type 2 diabetes mellitus with hyperosmolarity without nonketotic hyperglycemic-hyperosmolar coma (a severe life-threating complication of type 2 diabetes (extremely high blood glucose levels),Type 1 diabetes mellitus with diabetic nephropathy (nerve damage in hands, feet, and legs). Diverticulitis ofIntestine (inflammation of small, bulging pouches in the colon).Record Review of Resident 5's MDS dated [DATE] revealed a BIMS score of 8 (moderate cognitive impairment). Resident 5 required partial/moderate assistance in the areas of eating, oral hygiene, upper body dressing, and personal hygiene. Resident 5 required substantial/maximum assistance in toileting hygiene, shower/bathe self, and lower body dressing, putting on/taking off footwear, sit to lying on side of bed, sit to stand, and chair transfer.Record Review of Resident #5's Care plan dated 1/22/26 revealed the following:Problem: Resident 5 is at risk for dehydration due to presence of feeding tube related to diagnosis of anorexia (edited 2/27/26).Goal: Resident 5 will have a stable weight as evidenced by no significant weight loss of 5% or more in 30 days; or 10% or more in 180 days (edited 2/27/26).Approach: administer feeding via gtube per orders. Monitor hydration status and electrolytes (edited 9/7/25); Placement verification-check residual (if 150ml or less reinsert volume into stomach and continue feeding. If greater than 150ml, hold feeding and notify physician_created 6/17/25).Problem: Resident 5 is at risk for pressure injury related to immobility, incontinence, poor nutrition, decreased cognition, diabetes, and fragile skin (edited 2/27/26)Goal: resident's skin will remain intact over the next 90 days (edited 2/27/26)Approach: CNA to inspect skin, especially over bony prominences, during bathing and personal care and report fining to licensed nurse (edited 3/4/25); reposition resident as needed per tolerance (3/4/25);Problem: Resident 5 is at risk for falling r/t use of antianxiety medications, muscle weakness and arthritis (2/27/26)Goal: Resident 5 will remain free from injury through next 90 days (edited 2/27/26)Approach: Keep call light in reach at all times (3/4/25)On 3/9/26 at 7:50am during an observation in Resident 5's room where she was sitting on the side of her bed. She activated the call light at 7:50 am. At 8:10am RN A arrived in the room, walked past Resident, looked behind the curtain of residents' roommate who was not present, then proceeded to walk out of the room without addressing the activated call light.In an interview on 3/9/26 at 7:50am with Resident 5 she stated she very seldom uses the call light system; however, on one occasion she was extremely sick and pushed her call light and it was more than 30 minutes before it was answered. Resident 5 stated, I'm afraid that if I was dying I'd probably be dead before staff responds. Resident 5 stated this is an on-going problem on all shifts.In an interview on 3/5/26 at 10:00am Resident 3 stated she knows that it takes a long time for staff to answer call lights as she has heard the complaints from other residents. She stated it takes staff 30 minutes to 1 1/2 hours to answer call lights. In an interview on 3/5/26 at 10:30am Resident 4 stated she is the resident council secretary. She stated call lights are an on-going issue. She stated it takes more than 30 minutes for call lights to be answered. She stated these issues are in the resident council meeting minutes because she is the secretary.In a Telephone Interview on 3/5/26 at 4:45pm with Ombudsman- he stated call lights being answered in acceptable times have been an on-going issue and he has received multiple complaints. He stated night shift barely answers their call lights.In an interview on 3/9/26 at 7:43am with the ADON she stated in the matter of call lights, she believed there is a perception issue with residents. She stated there are enough CNAs and if need be, the MAs will and can assume the position of a CNA. In an interview on 3/9/26 at 8:10am with RN A he stated he was the WC nurse for the facility. RN A initially stated he was unaware of the call light being on. He was asked to step out of the room to see if the call light was on, which he stated was on. RN A stated he did not address the resident's needs, and he should have since she was the only resident in the room and the call light was on. RN A stated the failure to address the resident who activated the call light could have resulted in the resident being in some type of distress, which could have been bad for residents. He stated being a WC Nurse did not prevent him from answering a call light. He stated he should have. He stated this was an error on his behalf.In an interview on 3/9/26 at 8:15am with Resident 6 he stated he has an issue with night shift answering his call light. He stated he needs to be changed, and it takes more than 30 minutes for a response. He stated he has been left in soiled diaper because his light had not been answered. He stated the feeling of being left unattended makes him sad and feel worthless. He stated he does not have any wounds.In an interview on 3/9/26 at 8:30am with CMA B she stated some residents have complained about call lights not being answered; however, she stated she will assist CNAs whenever she can. She stated answering a call light after 30 minutes is not acceptable because the resident could be in a dangerous situation.In an interview on 3/9/26 at 10:10am with CNA A she stated she believed there is enough staff. She stated call lights should be answered within 2-5 minutes. She stated 30 minutes is too long. She stated an emergency could happen and the residents' needs would not be met. In an interview on 3/9/26 at 4:27pm DON stated she gets complaints about call lights rarely and when she does, she looks at the circumstances. She stated call lights should be answered as soon as possible. She stated everybody can answer a call light because if a call light is on it may be an emergency. She stated a call light on for 30 minutes or more is excessive.Record Review of Resident Council Meeting Minutes dated 1/7/26 revealed, There are long wait times to answer call lights.Record Review of Facility's Policy on Call Lights dated May 5, 2023 revealed the following:Respond to call lights and request for assistance as quickly as practicableStaff respond to emergency lights immediately

Based on interview and record review, the facility failed to provide pharmaceutical services including procedures to accurately administer medications to meet the needs of each resident for 1 of 1 resident (Resident 1) reviewed for pharmacy services.The LVN A failed to properly administer a narcotic medication to Resident 1 and documented that the medication was wasted.The LVN A failed to properly dispose of the unused narcotic medication by leaving the medication on the resident's side table without supervision.The LVN A failed to properly document a controlled drug in the narcotic record or receipt and disposition established for Resdent 1. These failures could impact residents who receive medications based on pharmaceutical recommendations. Findings include:Record review of Resident1's Face Sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease (air flow is restricted during breathing), Hypothyroidism (thyroid gland doesn't make enough hormone), Hyperlipidemia (plaque buildup in arteries), Schizophrenia (brain disorder), hypertension (blood flowed through the vessels with high force), Type 2 diabetes mellitus with hyperglycemia (Insulin resistant), Paraplegia (paralysis affecting the lower half of body).Record Review of Resident1's Care plan dated 3/6/2026 revealed the following:Problem: Resident1 requires assistance with ADLs (start dated 3/28/25 and edited 12/16/25)Goal: Resident1 will improve/maintain current ADL independence (start dated 3/28/25 and edited 12/16/25).Approach: Resident1 requires supervision x 1 with eating (8/19/25); assist resident as need with personal hygiene (3/28/25).Problem: Resident1 has a diagnosis of seizures and is at risk of injury (12/16/25)Goal: Resident1 will not injure self-secondary to seizure disorder (edited 12/16/25 and long-term goal target date 3/16/26).Approach: Keep call light within reach (3/28/25) Problem: Resident1 is at risk for falling r/t muscle weakness and impaired mobility, contractures (12/16/25).Goal: Resident1 will remain free from injury through the next 90 days (12/16/25).Resident was totally dependent on staff for all her ADLs and staff was to ensure the call light is within reach.Approach: Keep call light in reach at all times (3/28/25).Record review of Resident 1's physician orders revealed an order for Nucynta ER (tapentadol) 150 mg give one tablet once a day for a history of Pain.In an interview on 3/9/26 at 10:20am with Resident 1 she stated this weekend (3/7/26) a nurse put a narcotic pill in a cup and placed it on her side table. She stated she was informed that she has a pill on her desk by CNA B who had awakened her on 3/8/26 between 5:45-6:00am when she woke her up to provide care. Resident stated she informed RN B and showed him the pill, but he did not do anything. Resident 1 stated the pill is a narcotic (tapentadol). In a telephone interview on 3/9/26 at 10:30am with CNA B she stated she worked this weekend (3/7/26 & 3/8/26) from 6:00am - 10:0pm. She stated she went to Resident 1's room around 6:00am on 3/8/26 to give care. She stated she noticed a blue pill in a cup on Resident 1's side table. She stated she asked Resident 1 about the pill and Resident 1 told her that she did not know how that pill got there. She stated the nurse must have sat it there last (Saturday) night while she was asleep. She stated the resident told her she informed RN B at which time she exited Resident 1's room. Afterward, CNA B stated she returned to Resident 1's room and Resident 1 still had the pill in her possession.In a Telephone Interview on 3/9/26 at 11:14am with RN B he stated he worked this weekend (3/7/26 & 3/8/26) from 6am-6pm. He stated he spoke with Resident 1 about a pill. He stated he asked her why the pill was left. He stated Resident 1 had shown him the pill and at this time he took the pill in his possession. He stated he spoke with the night nurse, LVN A, who told him that she gave Resident 1 a PRN narcotic, then he stated LVN A signed it off in the narcotic book as being wasted because Resident 1 did not take it. RN B stated the pill should never have been left. RN B stated Resident 1 always takes her medication. RN B stated the negative effect with this issue is Resident 1 could have been overmedicated because it was a scheduled narcotic medication.In a Telephone Interview on 3/9/26 at 11:24am with LVN A she stated she worked at the facility Saturday and Sunday (3/7/26 & 3/8/26). She stated she was informed by CNA B regarding the narcotic pill in Resident 1's room. She stated she did administer medication. (3/7/26 & 3/8/26) She stated MA A signed out the pill and left it on Resident 1's table. She stated the pill was already signed out of the book when she looked at it. LVN A stated MA A was new and was supposed to be trained by a nurse. LVN A stated all medications administered to Residents are to be observed while the resident is taking the medication. LVN A stated Resident 1 could have been over-medicated or missed a dose all together.In a telephone interview on 3/9/26 at 12:00pm with LVN B she stated she did work this weekend from 6:00 AM to 6:00 PM (3/7/26 & 3/8/26). LVN B stated she trained MA A. She stated she was familiar with Resident 1's medication and observed MA A administering her narcotics (medication) in the morning. LVN B stated that at no time would she or her trainee ever place a pill in a cup and put it by any resident's desk. LVN B stated MAs are trained to administer medication to residents and observe them take the medication. She stated the negative effect to this issue is Resident 1 could have been heavily medicated or there are patients with dementia walking through the hall and going into peoples' rooms. One of them could have taken the medication.In an interview on 3/9/26 at 4:27pm with DON she stated the pill found in Resident 1's room was not appropriate. The resident could have been in pain or over-medicated.In a telephone interview on 3/9/26 at 4:45pm with CMA A she stated she completed orientation and training with LVN B. She stated she remembers administering scheduled medications only that morning. She stated she observed Resident 1 take the medication. She never administered in the evening. She stated the pill (Tapentadol) in the cup in question is PRN (given as needed) and only nurses can administer.Record Review of facility medication management program dated [complete revision: 5/5/23: revealed the following:10. the authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave medication in a resident room without order to do so.Record Review of Narcotic book titled, Controlled Drug Receipt/Record/Disposition Form for Resident. The name of the medication was NUCYNTA (tapentadol) (a strong narcotic pain reliever) ER TAB 150MG (Scheduled II). On 3/7/26 at 7p LVN A put amount given 1, amount left 10 her signature CBrown/wasted (missed dose)

Based on interview and record review, the facility failed to ensure that controlled medications, were properly secured, as evidenced by medications being left unattended and unsecured for 1 of 1 resident (Resident 1) reviewed for accurate labeling of drugs.The LVN A left a pill in Resident 1's room, on a side table unsecuredThis failure could place Resident 1 and other residents at risk of being overmedicated and possible of overdoseFindings include:Record review of Resident1's Face Sheet revealed a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses of Chronic obstructive pulmonary disease (air flow is restricted during breathing), Hypothyroidism (thyroid gland doesn't make enough hormone), Hyperlipidemia (plaque buildup in arteries), Schizophrenia (brain disorder), hypertension (blood flowed through the vessels with high force), Type 2 diabetes mellitus with hyperglycemia (Insulin resistant), Paraplegia (paralysis affecting the lower half of body).Record Review of Resident1's Care plan dated 3/6/2026 revealed the following:Problem: Resident1 requires assistance with ADLs (start dated 3/28/25 and edited 12/16/25)Goal: Resident1 will improve/maintain current ADL independence (start dated 3/28/25 and edited 12/16/25).Approach: Resident1 requires supervision x 1 with eating (8/19/25); assist resident as need with personal hygiene (3/28/25).Problem: Resident1 has a diagnosis of seizures and is at risk of injury (12/16/25)Goal: Resident1 will not injure self-secondary to seizure disorder (edited 12/16/25 and long-term goal target date 3/16/26).Approach: Keep call light within reach (3/28/25)Problem: Resident1 is at risk for falling r/t muscle weakness and impaired mobility, contractures (12/16/25).Goal: Resident1 will remain free from injury through the next 90 days (12/16/25).Resident was totally dependent on staff for all her ADLs and staff was to ensure the call light is within reach.Approach: Keep call light in reach at all times (3/28/25).Record review of Resident 1's physician orders revealed an order for Nucynta ER (tapentadol) 150 mg give one tablet once a day for a history of Pain.In an interview on 3/9/26 at 10:20am with Resident 1 she stated this weekend (3/7/26) a nurse put a narcotic pill in a cup and placed it on her side table. She stated she was informed that she has a pill on her desk by CNA B who had awakened her on 3/8/26 between 5:45-6:00am when she woke her up to provide care. Resident stated she informed RN B and showed him the pill, but he did not do anything. Resident 1 stated the pill is a narcotic (tapentadol).In a telephone interview on 3/9/26 at 10:30am with CNA B she stated she worked this weekend (3/7/26 & 3/8/26) from 6:00am - 10:0pm. She stated she went to Resident 1's room around 6:00am on 3/8/26 to give care. She stated she noticed a blue pill in a cup on Resident 1's side table. She stated she asked Resident 1 about the pill and Resident 1 told her that she did not know how that pill got there. She stated the nurse must have sat it there last (Saturday) night while she was asleep. She stated the resident told her she informed RN B at which time she exited Resident 1's room. Afterward, CNA B stated she returned to Resident 1's room and Resident 1 still had the pill in her possession. In a Telephone Interview on 3/9/26 at 11:14am with RN B he stated he worked this weekend (3/7/26 & 3/8/26) from 6am-6pm. He stated he spoke with Resident 1 about a pill. He stated he asked her why the pill was left. He stated Resident 1 had shown him the pill and at this time he took the pill in his possession. He stated he spoke with the night nurse, LVN A, who told him that she gave Resident 1 a PRN narcotic, then he stated LVN A signed it off in the narcotic book as being wasted because Resident 1 did not take it. RN B stated the pill should never have been left. RN B stated Resident 1 always takes her medication. RN B stated the negative effect with this issue is Resident 1 could have been overmedicated because it was a scheduled narcotic medication.In a Telephone Interview on 3/9/26 at 11:24am with LVN A she stated she worked at the facility Saturday and Sunday (3/7/26 & 3/8/26). She stated she was informed by CNA B regarding the narcotic pill in Resident 1's room. She stated she did administer medication. (3/7/26 & 3/8/26) She stated MA A signed out the pill and left it on Resident 1's table. She stated the pill was already signed out of the book when she looked at it. LVN A stated MA A was new and was supposed to be trained by a nurse. LVN A stated all medications administered to Residents are to be observed while the resident is taking the medication. LVN A stated Resident 1 could have been over-medicated or missed a dose all together.In a telephone interview on 3/9/26 at 12:00pm with LVN B she stated she did work this weekend from 6:00 AM to 6:00 PM (3/7/26 & 3/8/26). LVN B stated she trained MA A. She stated she was familiar with Resident 1's medication and observed MA A administering her narcotics (medication) in the morning. LVN B stated that at no time would she or her trainee ever place a pill in a cup and put it by any resident's desk. LVN B stated MAs are trained to administer medication to residents and observe them take the medication. She stated the negative effect to this issue is Resident 1 could have been heavily medicated or there are patients with dementia walking through the hall and going into peoples' rooms. One of them could have taken the medication.In an interview on 3/9/26 at 4:27pm with DON she stated the pill found in Resident 1's room was not appropriate. The resident could have been in pain or over-medicated.Record Review of facility medication management program dated [complete revision: 5/5/23: revealed the following:10. the authorized staff member or licensed nurse must remain with the resident while the medication is swallowed. Never leave medication in a resident room without order to do so.Record Review of Narcotic book titled, Controlled Drug Receipt/Record/Disposition Form for Resident. The name of the medication was NUCYNTA (tapentadol) (a strong narcotic pain reliever) ER TAB 150MG (Scheduled II). On 3/7/26 at 7p LVN A put amount given 1, amount left 10 her signature CBrown/wasted

Based on observation, interview and record review the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption, for 1 resident (Resident #1) of 8 residents reviewed in that:Resident #1's personal refrigerator located in Resident #1's room observed on 11/19/2025, revealed two undated containers of ice cream that had liquified and leaked onto the shelves of the refrigerator unit. Additionally, a clear plastic cup containing a red liquid was observed to have a lid on it with a date that read 10/28.This failure could place residents at risk of foodborne illness due to consuming foods that might be spoiled.The findings included:Review of Resident #1's face sheet, dated 11/19/2025, revealed that the resident was an [AGE] year-old female that had initially admitted to the facility on [DATE] with diagnoses that included: Dementia (a decline in mental ability), Polyneuropathy (numbness in extremities), Immunodeficiency (weakened immune system), and Type 2 diabetes mellitus (body does not produce/use insulin effectively). Record review of Resident #1's Quarterly MDS Assessment, dated 09/26/2025, reflected the resident's BIMS score was 11 out of a possible 15, which indicated moderate cognitive impairment, indicating problems with thinking and memory that may require assistance with daily tasks, and the resident required set up or clean-up assistance with eating.Record review of Resident #1's Comprehensive Care Plan, dated 09/25/2025, revealed the resident .requires assistance with ADLs at times. For intervention Resident requires supervision with eating at times.Record review of the Angel Rounds personal refrigerator temperature check logs, dated 10/01/25 to 10/31/25, for the 300 and 400 halls found that some staff members were marking all temperatures for personal refrigerators each day. Other staff members were only marking temperatures that were found to be over 42 degrees and left the other dates blank. Temperatures for Resident # 1, initialed by the Community Assistant, had all temperatures marked for each day, no temperatures for Resident #1 were found to be out of parameters.In an observation on 11/19/2025 at 11:33 AM it was revealed Resident #1 was not in their room. There was a personal refrigerator in the room, and inside the refrigerator there were two undated containers of ice cream that had liquified and leaked onto the shelves of the refrigerator unit. Additionally, a clear plastic cup containing a red liquid was observed to have a lid on it with a date that read 10/28.In an interview on 11/19/2025 at 1:50 PM with the ADON it was revealed that staff are to look into resident personal refrigerators on a daily basis during Angel Rounds where each department head had a list of assigned residents and that the staff were to mark resident's food found in their personal refrigerators with the date and also to record the temperature the personal refrigerator was at 41 degrees or below, and if they find spoiled foods to ask the resident if they can throw the items out.In an interview on 11/19/2025 at 2:00 PM with CNA A it was revealed that CNA staff do look into refrigerators for expired foods. CNA A stated that she did not know anything about temperature logs for personal refrigerators or what temperature a personal refrigerator was safe at. CNA A stated that they just make sure that the refrigerator is cold and not too warm.In an interview on 11/19/2025 at 2:22 PM with CNA B it was revealed that she did open resident personal refrigerators to look for expired foods and that she would ask the resident if she could throw an item out before she threw it away. CNA B stated that there were thermometers in the refrigerators and that 70 degrees would be too warm and that she would tell a nurse or the maintenance staff if a refrigerator was that hot. In an interview on 11/19/2025 at 2:34 PM with Community Assistant it was revealed that she participated daily in Angel Rounds where they went in and talked to residents they were assigned and checked on their rooms and personal refrigerators, and that she always marked down all personal refrigerator temperatures. She stated that Resident #1 was one of her assigned residents, but she was unaware that there were any expired foods in Resident #1's refrigerator. She stated that she vaguely remembered putting a date on some red Kool-Aid or something in Resident #1's refrigerator but did not remember any containers of ice-cream. Community Assistant stated that spoiled or expired foods should be taken out of resident personal refrigerators because if a resident was to eat spoiled or expired foods the resident could get sick. In an interview on 11/19/2025 at 4:21 PM with AD it was revealed that she participated in Angel Rounds where all department heads in the facility were supposed to go into resident rooms and check on the resident and the residents' personal refrigerators. She stated that she marked down all temperatures of the personal refrigerators she checked, but she was not sure if everyone did write the temperatures down. She stated that they do the checks to make sure that residents do not eat spoiled or expired foods. She stated that residents eating spoiled or expired foods could get sick from foodborne illnesses.In an interview on 11/19/2025 at 4:34 PM with DON it was revealed that department heads were assigned rooms to be checked every day during Angel Rounds, and that part of the Angel Rounds checks for each resident (daily) the staff were to check resident personal refrigerators for temperatures, date any foods found in the refrigerator with that day's date and dispose of any spoiled or expired foods. She stated that some of the staff were marking all temperatures but that they were to mark the temperatures only if they were above 41 degrees. She stated that the staff did this to make sure that residents did not eat spoiled or expired foods because that could expose residents to foodborne illnesses.In an interview on 11/20/25 at 9:11 AM with Resident #1 she stated that she hardly ever used her personal refrigerator. She stated that she didn't remember putting anything in the refrigerator in her room, but the staff kept everything clean and nice and she had no complaints about her care or treatment.In an interview on 11/20/2025 at 11:40 AM with DM it was revealed that she had trained the department heads and other staff on cold hold temperatures and expired foods. Open containers of juice or any liquids must be thrown out in at least 3 days, ice cream or other frozen treats should not be stored in the personal room fridges because they did not get cold enough to keep them frozen and once melted cannot be frozen again to be served. She stated that the staff participating in conducting Angel Rounds should be writing down temperatures whether they are in or out of parameters (41 degrees) and if over 41 degrees, notify maintenance.Record review of the facility policy, titled Foods brought by family/visitors, revised 06/2023, revealed . 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food - Perishable foods are stored in resealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item, and the use by date.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 3 of 7 (Residents #1,2, and 5) reviewed for food service safety. -The facility provided refrigerator located in the room of Resident #1 and #2 on 08/17/2025 was observed with a food item with an unknown use by date that appeared to be in a stage of decay, dead insects, and unpleasant odor. -The facility provided refrigerator located in the room of Resident #5 was observed to have expired ThickenLemon Flavored Water on 08/19/2025 with a package use by date of 05/09/2025. These failures could place residents at risk of foodborne illness and food contamination.Findings included:Record review of Resident#1's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis to include dementia, anxiety, and Dysphagia (difficulty swallowing). Record review of Resident#1's Quarterly MDS assessment dated [DATE] revealed in section C a BIMS score of 02 indicating she was severe cognitive impairment. She was assessed to have Mechanically altered diet in Section K. Record review of the EMR (electronic medical record) of Resident #1 revealed physician order dated 079/27/2023 for a Pureed Diet with no added salt. Record review of Resident #1's Care Plan dated 07/24/2025 revealed:Focus: Resident is at risk for malnutrition and/or dehydration related to: NAS pureed diet and dx of dementia.Goal: will maintain nutritional status as evidenced by no significant weight change through next review. Will receive appropriate diet as ordered by physician.Intervention: encourage intakes of foods and fluids, offer alternatives if intakes do not appear adequate.Record review of Resident#2's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis to include dementia, anxiety, and Dysphagia (difficulty swallowing).Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed in section C a BIMS score was not scored because the resident rarely/never understood indicating she had severe cognitive impairment. She was assessed to have a feeding tube and mechanically altered diet in Section K. Record review of the EMR (electronic medical record) of Resident #2 revealed physician order dated 04/01/2025 for a Pureed Diet Continue PEG for supplemental nutrition as needed.Record review of Resident #2's Care Plan dated 06/09/2025 revealed:Focus: Resident receives a House Pureed diet and is at risk for malnutrition and weight.fluctuations.Goal: receive adequate nutrition and fluid intake and will not experience significant weight fluctuations thru the next review date.Intervention: Serve diet as ordered per MD.Focus: receives enteral tube feeding to supplement oral intake as needed.Goal: will remain free of complications related to Gtube; including aspiration/infection.Intervention: Flush tube with 150 cc's warm water before and after tube feeding administration. Record review of Resident #5's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with primary diagnosis Naegleriasis (infection of the brain).Record review of Resident #5's admission MDS assessment dated [DATE] revealed in section C a BIMS score was not scored because the resident rarely/never understood indicating she had severe cognitive impairment. She was assessed to have a feeding tube in Section K. Record review of the EMR (electronic medical record) of Resident #5 revealed physician order dated 06/14/2025 for a diet NPO.Record review of Resident's #5's Care Plan dated 07/02/2025 revealed:Focus: is at risk for aspiration due to presence of feeding tube related to dysphagia fluctuations.Goal: not develop symptoms of aspiration until next review. Tolerate tube feeding as evidenced bystable weight, no s/sx complaints of bloating.Intervention: Administer feeding via g-tube as orderedFocus: is at risk for dehydration and weight fluctuations r/t NPO status.Goal: will be free from signs and symptoms of dehydration as evidenced by: moist mucous membranes, good skin turgor, and labs within normal limits. Intervention: h20 at 30 ml/hr(milliliter each hour) .In a phone interview on 08/19/2025 at 9:30am with Resident #1's family member, she said that when she visited on 08/17/2025 there was an odor coming from the refrigerator located in the room of Resident#1 and #2. She said that she opened the refrigerator and found what appeared to be dead gnats caused by decaying food inside. She said that she cleaned the refrigerator, discarded the items in the outside dumpster, and she did not speak to facility staff about her concerns. In an observation on 08/19/2025 at 10:30am video and photograph evidence were received from Resident #1's family member and dated Sunday at 3:48pm. The video and photographs showed a mini refrigerator with a brown bag on the bottom shelf, and what appeared to be small black insects on the bottom shelf. The video showed someone to open the brown bag, and inside contained what appeared to be a rotisserie chicken that was black with decay and with a white fuzzy substance on the chicken.In an observation on 08/19/2025 at 10:45am, the room of Resident#1 and #2 was cleared of food items refrigerator with no sign of insects. In an effort to interview both Resident#1 on 08/19/2025 at 10:45am, she was found to be non-interviewable. In an effort to interview both Resident#2 on 08/19/2025 at 10:50am, she was found to be non-interviewable. In an interview and observation on 08/19/2025 at 11:05am with Nurse Aide A, she said that food items stored in the refrigerators located in the resident's room should be discarded in 3 days of being placed inside the refrigerator, discarded after the use by date if in the original container, because the items or no longer safe to consume and residents to become sick. She did not know who had the responsibility to clean out refrigerators and discard outdated food items located in the residents' room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control.In an interview and observation on 08/19/2025 at 11:10am with Housekeeper, she said that the housekeepers should check the refrigerators located in the resident's room daily for cleanliness, and she should report to nursing staff if there is outdated food found. She said that if residents ate outdated food, it could cause them to become sick. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:15am with RN B, he said that food items stored in the refrigerators located in the resident's room should be discarded in 3 days of being placed inside the refrigerator, discarded after the use by date if in the original container, because the items or no longer safe to consume and the risk to residents would be food borne illness. He said that he did not know who had the responsibility to clean out refrigerators located in the resident's room or how often. He said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control.In an interview and observation on 08/19/2025 at 11:05am with Nurse Aide C, she said that food items stored in the refrigerators located in the resident's room should be discarded in 3 days of being placed inside the refrigerator, discarded after the use by date if in the original container, because the items or no longer safe to consume and residents to become sick. She did not know who had the responsibility to clean out refrigerators and discard outdated food items located in the residents' room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control.In an interview on 08/19/2025 at 11:25am with ADON D, she said that food items stored in the refrigerators located in the resident's room should be stored until the package use by date if in the original container or 72 hours if removed from the original package. She said that that if a resident consumed food after the use by date it could cause foodborne illness. She was unsure who should check the refrigerator in the resident's room for cleanliness and outdated food, how often the refrigerator should be checked, or how it should be documented. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an observation on 08/19/2025 at 11:30am, the room of Resident#5 was observed to have expired Thicken Lemon Flavored Water (designed to provide hydration and comfort for individuals with swallowing difficulties) with a package use by date of 05/09/2025. In an effort to interview both Resident#5 on 08/19/2025 at 11:30am, she was found to be non-interviewable with Gastrostomy Tube (a surgically placed device used to give direct access to the stomach for supplemental feeding) in place. In an interview and observation on 08/19/2025 at 11:36am with Nurse Aide F, she said that food items stored in the refrigerators located in the resident's room should be discarded in 3 days of being placed inside the refrigerator, discarded after the use by date if in the original container, because the items or no longer safe to consume and residents to become sick. She did not know who had the responsibility to clean out refrigerators and discard outdated food items located in the residents' room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. She was observed to look into the refrigerator located in the room of Resident#5 and pull out Thicken Lemon Flavored Water. She said that the item should have been thrown out after it expired on 05/09/2025. She said that the item did not belong to the resident because the Resident#5 does not consume food and has a feeding tube. She was observed to take the item to the nurse station and give it to RN B. In an interview and observation on 08/19/2025 at 11:40am with RN B, he said that Resident #5 had a continuous feeding tube and did not consume food items. He said that Thicken Lemon Flavored Water was used for residents with difficulty swallowing. He said that the item should have been thrown out after the use by date of 05/09/2025. He was observed to take the item to ADON E.In an interview on 08/19/2025 at 11:45am with ADON E and the DON, both said that food items stored in the refrigerators located in the resident's room should be stored until the package use by date if in the original container or 72 hours if removed from the original package. Both said that that if a resident consumed food after the use by date it could cause foodborne illness. Both were unsure who should check the refrigerator in the resident's room for cleanliness and outdated food, how often the refrigerator should be checked, or how it should be documented. Both said that Resident #5 had a continuous feeding tube and did not consume food items. Both said that Thicken Lemon Flavored Water was used for residents with difficulty swallowing. Both said that the item should have not been stored in the resident room and thrown out after the use by date of 05/09/2025. Both said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. Both viewed the video of taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and what could be insects. In an interview on 08/19/2025 at 1:00pm with the Administrator and [NAME] President of Regulator Compliance, with the DON present. Both said that that nursing staff should check the contents of the refrigerators daily when the daily temperature is checked to ensure that outdated food is discarded, cleanliness of refrigerator and proper cooling. Both said that the daily checks should be documented on the log daily that it was being completed. Both said that food items stored in the refrigerators located in the resident's room should be stored until the package use by date if in the original container or 72 hours if removed from the original package. Both said that that if a resident consumed food after the use by date it could cause foodborne illness. Both said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. Both viewed the video of taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and what could be insects. In an interview on 08/19/2025 at 1:33pm with the Maintenance Director, who said that he also oversees the housekeeping department. He said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. He viewed the video taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and dead gnats. He said that housekeepers should check the refrigerators in the resident's room daily to ensure that they are sanitary, free of pest control issues, and report any signs of pest control him immediately. He that he was not sure who should be checking for food storage, labeling, and expiration date of food in the resident's room. He said that if staff were checking daily the refrigerator in the room of Resident#1 and 2 would not have been found in the condition viewed in the video. In an interview on 08/19/2025 at 1:44pm with the Dietary Manager, who said that said that food items stored in the refrigerators located in the resident's room should be stored until the package use by date if in the original container or 72 hours if removed from the original package. She said that that if a resident consumed food after the use by date it could cause foodborne illness. She said that that nursing staff held the responsibility of checking for food storage, labeling, and expiration date of food in the residents room, and they should check daily. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control.Record review of facility policy titled, Nutrition Policies and Procedures and dated 06/20/2023, read in part, Subject: Pest Control Policy: Facility will maintain an effectives pest control program to prevent or eliminate infestation of pest and rodents. Procedures:.5. Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests.Record review of facility policy titled, Nutrition Policies and Procedures, dated 06/20/2023 read in part, Subject: Food Safety In receiving and Storage Policy: Food will be received and stored by methods to minimize contamination and bacterial growth.6.Check expiration dates and use-buy dates to assure the dates are within acceptable parameters.Record review of facility policy titled, Nutrition Policies and Procedures, dated 06/20/2023 read in part, Subject: Food From Outside Sources, Safe Handling of Policy: Food served by the facility is purchased from commercial vendors that comply with federal, state, and local regulations. However, patients or residents have the right to choose to make choices, including the right to accept food from family, friends, or order foods for delivery. The facility discourages sharing of food with other residents due to the individual dietary requirements and varying consistency needs of individuals. The facility is responsible for ensure that goods brought into the facility from outside have been prepared and delivered using safe food handling practices.3. To the extent possible, nursing staff monitors the food provided for patients or residents by outside sources to verify safe handling/storage and appropriateness for the recommended dietary needs of the individual patient/resident.5. Foods are labeled to identify the patient/resident's name, container contents, and the date it was prepared. Food items are stored in disposable, tightly covered containers, or sealable plastic bags. Items will be stored for three (3) days. Expired and unlabeled items will be discarded.

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 7 (Residents #1 and #2) resident rooms reviewed for environment.-The facility provided refrigerator located in the room of Resident #1 and #2 on 08/19/2025 was observed with dead insects.This failure has the potential to placed residents at risk for disease and a decline in their physical health. Findings included:Record review of Resident#1's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis to include dementia, anxiety, and Dysphagia (difficulty swallowing). Record review of Resident#1's Quarterly MDS assessment dated [DATE] revealed in section C a BIMS score of 02 indicating she was severe cognitive impairment. She was assessed to have Mechanically altered diet in Section K. Record review of the EMR (electronic medical record) of Resident #1 revealed physician order dated 079/27/2023 for a Pureed Diet with no added salt. Record review of Resident #1's Care Plan dated 07/24/2025 revealed:Focus: Resident is at risk for malnutrition and/or dehydration related to: NAS pureed diet and dx of dementia.Goal: will maintain nutritional status as evidenced by no significant weight change through next review. Will receive appropriate diet as ordered by physician.Intervention: encourage intakes of foods and fluids, offer alternatives if intakes do not appear adequate.Record review of Resident#2's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis to include dementia, anxiety, and Dysphagia (difficulty swallowing).Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed in section C a BIMS score was not scored because the resident rarely/never understood indicating she had severe cognitive impairment. She was assessed to have a feeding tube and mechanically altered diet in Section K. Record review of the EMR (electronic medical record) of Resident #2 revealed physician order dated 04/01/2025 for a Pureed Diet Continue PEG for supplemental nutrition as needed. Record review of Resident #2's Care Plan dated 06/09/2025 revealed:Focus: Resident receives a House Pureed diet and is at risk for malnutrition and weight.fluctuations.Goal: receive adequate nutrition and fluid intake and will not experience significant weight fluctuations thru the next review date.Intervention: Serve diet as ordered per MD.Focus: receives enteral tube feeding to supplement oral intake as needed.Goal: will remain free of complications related to Gtube; including: aspiration/infection.Intervention: Flush tube with 150 cc's warm water before and after tube feeding administration.In a phone interview on 08/19/2025 at 9:30am with Resident #1's family member, she said that when she visited on 08/17/2025 there was an odor coming from the refrigerator located in the room of Resident#1 and #2. She said that she opened the refrigerator and found what appeared to be dead gnats caused by decaying food inside. She said that she cleaned the refrigerator, discarded the items in the outside dumpster, and she did not speak to facility staff about her concerns. In an observation on 08/19/2025 at 10:30am video and photograph evidence were received from Resident #1's family member and dated Sunday at 3:48pm. The video and photographs showed a mini refrigerator with a brown bag on the bottom shelf, and what appeared to be small black insects on the bottom shelf. In an observation on 08/19/2025 at 10:45am, the room of Resident#1 and #2 was cleared of food items in the cabinet and refrigerator with no sign of insects. In an effort to interview both Resident#1 on 08/19/2025 at 10:45am, she was found to be non-interviewable. In an effort to interview both Resident#2 on 08/19/2025 at 10:50am, she was found to be non-interviewable. In an interview and observation on 08/19/2025 at 11:05am with Nurse Aide A, she said that she did not know who had the responsibility to clean out refrigerators located in the residents' room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:10am with Housekeeper, she said that the housekeepers should check the refrigerators located in the resident's room daily for cleanliness. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:15am with RN B, he said that he did not know who had the responsibility to clean out refrigerators located in the resident's room or how often. He said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:05am with Nurse Aide C, she said that she did not know who had the responsibility to clean out refrigerators located in the resident's room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest controlIn an interview on 08/19/2025 at 11:25am with ADON D, she said that she was unsure of who or how often the refrigerators in the resident's room should be checked for cleanliness, or how it was documented. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview on 08/19/2025 at 11:45am with ADON E and the DON, both said that were unsure of who or how often should the refrigerators in the resident's room be checked for cleanliness, or how it was documented. Both said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. Both viewed the video of taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and what could be insects. In an interview on 08/19/2025 at 1:00pm with the Administrator and [NAME] President of Regulator Compliance, both said that nursing staff should check the contents of the refrigerators daily when the daily temperature is checked to ensure that outdated food is discarded, cleanliness of refrigerator and proper cooling. Both said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. Both viewed the video of taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and what could be insects. In an interview on 08/19/2025 at 1:33pm with the Maintenance Director, who said that he also oversees the housekeeping department. He said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. He viewed the video taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and dead gnats. He said that housekeepers should check the refrigerators in the resident's room daily to ensure that they are sanitary, free of pest control issues, and report any signs of pest control him immediately. He said that if staff were checking daily the refrigerator in the room of Resident#1 and 2 would not have been found in the condition viewed in the video. Record review of facility policy titled, Nutrition Policies and Procedures and dated 06/20/2023, read in part, Subject: Pest Control Policy: Facility will maintain an effectives pest control program to prevent or eliminate infestation of pest and rodents. Procedures:.5. Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests.]

Based on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 7 (Residents #1 and #2) resident rooms reviewed for environment.-The facility provided refrigerator located in the room of Resident #1 and #2 on 08/19/2025 was observed with dead insects.This failure has the potential to placed residents at risk for disease and a decline in their physical health. Findings included:Record review of Resident#1's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis to include dementia, anxiety, and Dysphagia (difficulty swallowing). Record review of Resident#1's Quarterly MDS assessment dated [DATE] revealed in section C a BIMS score of 02 indicating she was severe cognitive impairment. She was assessed to have Mechanically altered diet in Section K. Record review of the EMR (electronic medical record) of Resident #1 revealed physician order dated 079/27/2023 for a Pureed Diet with no added salt. Record review of Resident #1's Care Plan dated 07/24/2025 revealed:Focus: Resident is at risk for malnutrition and/or dehydration related to: NAS pureed diet and dx of dementia.Goal: will maintain nutritional status as evidenced by no significant weight change through next review. Will receive appropriate diet as ordered by physician.Intervention: encourage intakes of foods and fluids, offer alternatives if intakes do not appear adequate.Record review of Resident#2's Face Sheet dated 08/19/2025 revealed, a [AGE] year-old female who admitted to the facility on [DATE] with diagnosis to include dementia, anxiety, and Dysphagia (difficulty swallowing).Record review of Resident#2's Quarterly MDS assessment dated [DATE] revealed in section C a BIMS score was not scored because the resident rarely/never understood indicating she had severe cognitive impairment. She was assessed to have a feeding tube and mechanically altered diet in Section K. Record review of the EMR (electronic medical record) of Resident #2 revealed physician order dated 04/01/2025 for a Pureed Diet Continue PEG for supplemental nutrition as needed. Record review of Resident #2's Care Plan dated 06/09/2025 revealed:Focus: Resident receives a House Pureed diet and is at risk for malnutrition and weight.fluctuations.Goal: receive adequate nutrition and fluid intake and will not experience significant weight fluctuations thru the next review date.Intervention: Serve diet as ordered per MD.Focus: receives enteral tube feeding to supplement oral intake as needed.Goal: will remain free of complications related to Gtube; including: aspiration/infection.Intervention: Flush tube with 150 cc's warm water before and after tube feeding administration.In a phone interview on 08/19/2025 at 9:30am with Resident #1's family member, she said that when she visited on 08/17/2025 there was an odor coming from the refrigerator located in the room of Resident#1 and #2. She said that she opened the refrigerator and found what appeared to be dead gnats caused by decaying food inside. She said that she cleaned the refrigerator, discarded the items in the outside dumpster, and she did not speak to facility staff about her concerns. In an observation on 08/19/2025 at 10:30am video and photograph evidence were received from Resident #1's family member and dated Sunday at 3:48pm. The video and photographs showed a mini refrigerator with a brown bag on the bottom shelf, and what appeared to be small black insects on the bottom shelf. In an observation on 08/19/2025 at 10:45am, the room of Resident#1 and #2 was cleared of food items in the cabinet and refrigerator with no sign of insects. In an effort to interview both Resident#1 on 08/19/2025 at 10:45am, she was found to be non-interviewable. In an effort to interview both Resident#2 on 08/19/2025 at 10:50am, she was found to be non-interviewable. In an interview and observation on 08/19/2025 at 11:05am with Nurse Aide A, she said that she did not know who had the responsibility to clean out refrigerators located in the residents' room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:10am with Housekeeper, she said that the housekeepers should check the refrigerators located in the resident's room daily for cleanliness. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:15am with RN B, he said that he did not know who had the responsibility to clean out refrigerators located in the resident's room or how often. He said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview and observation on 08/19/2025 at 11:05am with Nurse Aide C, she said that she did not know who had the responsibility to clean out refrigerators located in the resident's room or how often. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest controlIn an interview on 08/19/2025 at 11:25am with ADON D, she said that she was unsure of who or how often the refrigerators in the resident's room should be checked for cleanliness, or how it was documented. She said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. In an interview on 08/19/2025 at 11:45am with ADON E and the DON, both said that were unsure of who or how often should the refrigerators in the resident's room be checked for cleanliness, or how it was documented. Both said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. Both viewed the video of taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and what could be insects. In an interview on 08/19/2025 at 1:00pm with the Administrator and [NAME] President of Regulator Compliance, both said that nursing staff should check the contents of the refrigerators daily when the daily temperature is checked to ensure that outdated food is discarded, cleanliness of refrigerator and proper cooling. Both said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. Both viewed the video of taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and what could be insects. In an interview on 08/19/2025 at 1:33pm with the Maintenance Director, who said that he also oversees the housekeeping department. He said that food should not be left to rot and mold inside a refrigerator, because it could cause a smell or issue with pest control. He viewed the video taken of the refrigerator located in the room of Resident#1 and #2, and said it appeared to have food that was expired and dead gnats. He said that housekeepers should check the refrigerators in the resident's room daily to ensure that they are sanitary, free of pest control issues, and report any signs of pest control him immediately. He said that if staff were checking daily the refrigerator in the room of Resident#1 and 2 would not have been found in the condition viewed in the video. Record review of facility policy titled, Nutrition Policies and Procedures and dated 06/20/2023, read in part, Subject: Pest Control Policy: Facility will maintain an effectives pest control program to prevent or eliminate infestation of pest and rodents. Procedures:.5. Proper sanitation will be maintained, and clutter reduced to prevent food and harborage for pests.]

Based on observation, interview and record review, it was determined the facility failed to have written policies and procedures regarding the visitation rights of residents, including those setting forth any safety restriction or limitation and the reason for the safety restriction or limitation for 1 of 23 residents (Resident #67) reviewed for resident rights. The facility failed to have written policies and procedures regarding visitation rights of residents when Resident #67's family member was no longer allowed to visit the facility after 1/27/25. This failure placed residents at risk of inaccurate or incomplete information, decreased emotional wellbeing and diminished quality of life. Findings included: Record review of Resident #67's Continuity of Care Document generated on 7/31/25 revealed he was readmitted on [DATE] with diagnoses of parkinsonism (a clinical syndrome characterized by tremor, bradykinesia, rigidity and postural instability), anxiety, psychosis (a mental disorder characterized by a disconnection from reality) and morbid obesity. He was [AGE] years of age. Record review of Resident #67's quarterly MDS assessment dated [DATE] revealed he had a BIMS of 9, indicating moderate cognitive impairment. He was dependent on staff to complete chair/bed-to-chair transfers and did not walk or sit on the side of the bed due to his medical condition or safety concerns. Record review of Resident #67's progress note dated 1/19/25 revealed a note written by LVN T that reflected Resident #67's family member was at the nurse's station yelling, screaming and threatening staff, and upset stating, my (family member's) food looks disgusting. Then the family member brought his tray and stated that it was not up to quality guidelines, then took pictures of the food. The nurse asked if she wanted to fill out a grievance form, and the family member stated she knew how to file a complaint. Record review of a document provided by the facility (undated) revealed a CNA (unspecified) unpacked Resident #67's personal belongings and discovered a firearm. The CNA alerted LVN E who secured the firearm until police arrived. The document contained two statements from LVN E and Resident #67. The statement from LVN E indicated a police report and charges were filed on behalf of the facility for unlawfully carrying a weapon, and the weapon was confiscated by the police for examination and evidence. The statement from Resident #67 indicated that the weapon belonged to him, and his family member may have brought it when he was admitted . Resident #67 could not state whether the police of his family member had the weapon. The following actions were listed on the document: ' .legal contacted related to incident, legal sent documentation that visitation was revoked due to (family member's) escalated behaviors, staff educated on revoking visitation of (family member), resident interviewed and asked if he would like to help find another facility so he can visit with his (family member) and resident stated he liked it here and he could talk to her on the phone because 'I know how my (family member) is.' In an interview and observation on 7/30/25 at 2:30pm, Resident #67 stated he was a [NAME] and [NAME]. He said his family member brought his belongings in the facility when he readmitted in January 2025. He said there was a gun in his belongings. He said when the facility staff found the gun, they said his family member could no longer visit. He said it was too harsh of a punishment. He said that his family member was threatening to call the state (HHSC), but did not threaten violence. He said she was overzealous and gung-ho about his care. He said he had not seen his family member in 7 months, and it was hell not seeing her. He started to cry during the interview. He said she brought him meals to eat at the front door of the facility. In an interview on 7/30/25 at 3:34pm, LVN E said when Resident #67 moved in, his family member did not threaten violence. When asked if she said anything threatening, he said she did not say anything threatening, and stated It was the way she spoke to people, they felt threatened by her. He said the CNAs were scared of her and stated that they did not want to come to work if she was there. In an interview on 7/31/25 at 10:50am, the Social Worker said she had no interactions with Resident #67's family member prior to the decision not to allow her to visit. She said now, the family member brought Resident #67 food and clothes but did not enter the facility. She said they facetime, but it was not the same as hugging, touching or holding. In a telephone interview on 7/31/25 at 12:03pm, the Weekend Supervisor stated she did not witness Resident #67's family member threaten anyone and she was not violent. She said she had to ask the family member to calm down or watch her language before she would talk to her. She described the family member as passive aggressive. In an interview with on 7/31/25 at 1:00pm, the Administrator said when he learned of Resident #67 having a gun, he notified their legal department, completed an investigation and the legal department determined the resident's family member could no longer visit the facility. He said they took a statement from Resident #67 who said he did not realize the gun was in his room and that it was brought in with his belongings. He said his statement was the only piece of evidence they obtained during the investigation of the gun entering the facility. He said he did not interview Resident #67's family member. He said Resident #67's family member was verbally abusive toward staff. He said he met with her to explain that it was not appropriate in this setting. He said based on the family member's behavior and the gun incident, they decided she could no longer visit the facility. He said he could not remember how it was determined that the decision was not a violation of the resident rights. In an interview on 7/31/25 at 5:00pm, the DON said Resident #67's family member was belligerent and ignorant. She said there was never a calm moment, and she was never decent. She said at times, she disturbed the residents. She said the staff were complaining about her, and she cursed her out and would trail behind her. In an interview on 8/1/25 at 1:30pm, LVN T said Resident #67's family member was ugly, defensive and very short. She said she felt bad because that's her (Resident #67's family member), but she can't come due to the circumstances of denied visitation. In an interview on 8/1/25 at 3:11pm, Resident #67's family member stated Resident #67 moved into the facility for long-term care in January 2025. She said the Friday after he was readmitted on [DATE], she brought in his belongings. She said his home health aides packed his bags, so she did not know what was in them. She said she did not unpack his belongings when she dropped them off at the facility. She said the staff found the gun the next day. She said she did not meet with the police at the facility. She said she talked to the police department in April 2025 and they said they did not have any record of charges against her regarding the gun or trespassing. She said the facility notified her that she could no longer visit on 1/20/25, and they said she would receive a letter detailing the letter of trespassing. She said she did not receive anything until May 2025. She said they stereotyped her as an African American woman. She said the language they use to describe her, including disruptive and threatening, was racist. She said she got excited and raised her voice but did not yell at the top of my lungs. She said when she checked on Resident #67, she would find something wrong and take pictures. She said she was not intentionally finding stuff wrong. She said, You can't penalize me because I advocate for him. Record review of a letter addressed to Resident #67's family member dated 1/27/25 reflected in part, The purpose of this correspondence is to inform you that are no longer permitted to visit (Resident #67) at our facility or to enter the facility grounds for any reason. You were physically escorted by the police from the facility yesterday, January 26, 2025, because you were verbally threatening and intimidating staff members and other residents. A gun was found in (Resident #67's) room which (Resident #67) confirmed legally belonged to him but denied brining it into the facility and he believes you brought it into the facility. Additionally, staff have had multiple concerns about the manner in which you communicate, including but not limited to, yelling, cursing, threats of physical aggression, and persistent communications perceived as harassment. The concerns have been discussed with you previously in the past week and you acknowledge understanding. In an interview on 8/1/25 at 5:15pm, the Administrator said they would not allow Resident #67's family member to come for supervised visits. He said Resident #67 could go outside the facility to visit with her, go out on pass, or she could see him through the window. He said it was too risky to have her inside the facility. In an interview on 8/12/25 at 3:08pm, the Administrator said when he spoke to Resident #67's family member, they did not discuss a facility policy, he only discussed appropriate behavior in the facility. He said he was unaware of a visitation policy other than the policies provided. Record review of a Social Services Policy and Procedure regarding Resident Rights dated 6/9/23 revealed in part, The Facility employs measures to ensure patient and resident personal dignity, well-being and self-determination are maintained and will educate patients and residents regarding their rights and responsibilities. the resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. The policy did not explain those situations where visitors may be restricted due to safety concerns. Record review of a facility policy regarding Visitation-Resident Right dated 11/18/21 revealed in part, The Facility's staff will honor the patient and resident right to have personal visitation according to visitation guidance. The facility will implement measures to ensure patient, resident, staff and visitor safety during the visitation time. The facility will notify visitors and residents of the potential risk for exposure to COVID-19 in the facility. Required Visitation. The Facility will not restrict visitation without clinical or safety cause. The policy did not explain those situations where visitors may be restricted due to safety concerns.

Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and time frames to meet resident's medical, nursing, and mental and psychological needs that were identified in the comprehensive assessment for 1 out of 5 residents (Resident #8), reviewed for care plans. The facility failed to: - Update Resident #8's care plan with her correct code status and had both full code and DNR on it. The care plan also was not updated with the correct tube feeding. These failures could place residents at risk for not obtaining/maintaining their highest practicable wellbeing. Findings include: Record review of Resident #8's undated face sheet revealed she was a [AGE] year-old female originally admitted on [DATE], with the most recent admission on [DATE]. She had diagnoses of cerebrovascular infarction (stroke), hemiplegia and hemiparesis (paralysis and weakness), tracheostomy (tube into throat for breathing), gastrostomy (tube into stomach for nutrition), quadriplegia (paralysis in both arms and legs), aphasia (trouble speaking), dysphagia (trouble swallowing), and stage 4 pressure ulcer to sacral region (ulcer deep enough to show bone in the tailbone area). Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed a BIMS could not be completed because of the resident's medical condition. The resident had severely impaired cognitive skills for daily decision making. Resident #8 had impairment on both sides of her upper and lower extremities and was dependent with all ADL's (helper does all of the effort). The MDS confirmed the resident had a feeding tube and received 51% or more of her total calories through it. The MDS also revealed the resident had a stage 4 pressure ulcer and a tracheostomy. Record review of Resident #8's care plan dated 7/3/25, revealed a Focus: Advanced Care Planning: Code Status DNR (Start: 2/14/25, Revised: 7/24/25). The goal was to be informed of her right to complete the advanced directive to direct medical care (Target Date: 10/24/25, Revised: 7/24/25). The intervention was the advanced directive was completed and placed in the medical record (Start: 2/14/25). Focus: Resident #8 requests for be full code status (Start: 4/21/24, Revised: 7/24/25). The goal was that the resident's wishes and directions would be carried out in accordance with the advanced directives through the review date (Target Date: 10/24/25, Revised: 7/24/25). The interventions included arranging for clergy or social services as directed and discussing advanced directives with the resident or RP (Start: 4/21/24). Focus: Resident #8 received nutrition and hydration via g-tube (tube into stomach for nutrition) and was at risk for malnutrition and dehydration (Start: 4/21/24, Revised: 7/24/25). The goal was that Resident #8 would remain free of complications related to the g-tube (Target Date: 10/24/25, Revised: 7/24/25). Interventions included enteral (delivery of nutrients directly into digestive system) feeding: formula-Bolus (all at one time) feeding with Isosource HN 1.2 (type of feeding) 165ml TID via g-tube and flush tube with 150ml warm water before and after tube feeding administration (Start: 4/21/24.) Record review of Resident #8's Physician Orders from 7/31/25, revealed the following orders from MD H:- Code Status: Full Code. Ordered on 10/10/24 at 5:42pm. Discontinued on 1/3/25 at 10:57am.- Bolus Feeding Isosource HN 1.2 165ml TID via g-tube. Ordered on 4/17/24. Discontinued on 4/29/24 at 11:59am.- Code Status: DNR. Ordered on 1/5/25 at 1:32pm.- Enteral Feeding: Formula Two Kal HN 2.0 (type of feeding) 38ml/hr x 22hr via pump per g-tube with 275ml water flush via pump Q4hr. Ordered on 4/29/25. Record review of Resident #8's Dietary Progress Notes revealed a note from 5/15/24 at 1:41pm from RD W, revealed RD W recommended discontinuing the Isosource 1.2 bolus QID. Record review of Resident #8's Dietary Progress Notes revealed a note from 9/13/24 at 3:27pm from RD W that said the resident was receiving EN 2 Kcal HN at 45ml Qhr x 22hr. In an observation on 7/29/25 at 9:45am, Resident #8 was lying in bed with a disconnected feeding tube next to her bed. The bag that was hanging was 2 Kal HN. In an interview on 7/31/25 at 2:50pm with the DON, she said the SW, or a nurse updated the care plan depending on what it was about. She said a nurse or the SW would update the code status or the type of tube feeding. She said the specifics of the tube feeding should not have been on the care plan because things changed so frequently. The DON said the MDS coordinator must have done a mass update on the care plans on 7/3/25 because the resident was not due for her review, and she must have missed the code status and tube feeding. She said having the incorrect code status on the care plan would not affect anything because DNR was listed in the resident's chart, and in the code book. She said the correct tube feeding was also ordered in the resident's chart so it would not have affected anything either. Record review of the facility's policy and procedure on Person-Centered Care Plan (Revised 10/1/20) read in part: .Will be reviewed and updated as needs are identified and after each MDS assessment (excluding discharge). The person-centered care plan is interdisciplinary and created to guide facility staff in providing the treatment, care and services necessary for the patient/resident to obtain and maintain the highest physical, mental, and psychosocial well-being possible.

Based on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 7%, based on 2 errors out of 27 opportunities, which involved 1 of 6 residents (Resident #11) reviewed for medication errors. MA V administered Oyster shell calcium instead of Calcium with Vitamin D to Resident #11 and administered Visine eye drops to both eyes instead of to the left eye only according to the Physician orders on 7/30/25. These failures could place residents at risk of inadequate therapeutic outcomes.Findings include: Record review of Resident #11's face sheet revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included in part, mild intellectual disabilities, metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), asthma, schizophrenia, hypertension, and heart disease. Record review of Resident #'11's quarterly MDS assessment dated [DATE] revealed a BIMS score of 8 out of 15 which indicated moderate cognitive impairment. She required supervision or touching assistance with ADL care. Record review of Resident #11's care plan dated 5/23/25 revealed she had sneezing, watery eyes, scratchy throat, congestion headache related to seasonal allergies. The approach was to administer medications per order. Record review of Resident #11's Physician orders for July 2025 revealed orders for: Oyster Shell Calcium-Vit D3 500 mg - 5 mcg (200 unit); one tablet twice a day, order date 2/6/25;Visine dry eye relief 1% one drop in left eye three times a day, order date 2/6/25; In an observation on 7/30/25 at 7:28 a.m. revealed MA V prepared Resident #11's medication for administration. She prepared 14 medications which included Oyster shell calcium 500 mg (without Vitamin D) and Visine eye drops. MA V entered Resident #11's room and administered her the medication. Observation of the Visine eye drops revealed she administered one drop in Resident #11's left eye and one drop in her right eye. In an observation and interview on 7/30/25 at 7:53 a.m., MA V retrieved the Oyster shell calcium 500 mg from the medication cart and said she did not see Vitamin D3 listed as an ingredient on the medication bottle but only saw the Calcium. She said when she prepared the medication for Resident #11, she did not see the Vitamin D3 portion listed on the order. She said she did not have the combination of Calcium and Vitamin D3 available on her cart. She said the facility used to have the combination medication. She said the medication administered to Resident #11 and the medication prescribed were not same because of the Vitamin D3. She said she could notify her nurse or supervisor to change the order. MA V said the MD order for Visine eye drops was one drop in the left eye. She said she did not pay attention and should have read the directions on the order. She said the resident previously had an order for one drop in both eyes. She said the resident could have an allergic reaction. In an interview on 7/31/25 at 3:40 p.m. the DON said Resident #11 should have received whatever the order was written for. She said if the medication was not available the medication aide should mark the medication as not available, continue with the medication pass, look in the medication room for the medication and notify the nurse. She said the medication aide should not have picked up whatever was on the cart. She said when administering medications staff should read the bottle and only administer what was ordered. She said if the medication was not available it should have been documented. She said staff could also refer to the standing order and notify the MD for a change in order. The DON said when administering eye drops staff should check and verify the order. Record review of the facility's Medication Management Program revised 7/1/2016 read in part, .Preparing for the Medication Pass. 4. Authorized staff must understand. D. The 8 Rights for administering medication: . 2. The Right Drug, 3. The Right Dose.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 8 residents (Residents #48, #11 and #79) reviewed for infection control.The facility failed to ensure contents from Resident #48's consumed breakfast tray did not spill onto Resident #11's and #79's unconsumed lunch tray on 7/29/25. This failure could place residents at risk of infection. Findings include:Record review of Resident #48's face sheet revealed a [AGE] year-old male who admitted on [DATE]. His diagnoses included in part, age related cognitive decline, type 2 diabetes, disturbances in tooth eruption, diarrhea, seasonal allergic rhinitis, localized swelling, mass and lump, lower limb, and asthma.Record review of Resident #11's face sheet revealed a [AGE] year-old female who admitted on [DATE]. Her diagnoses included in part, mild intellectual disabilities, metabolic encephalopathy (a brain dysfunction caused by underlying metabolic disturbances, leading to symptoms like confusion, memory loss, and altered consciousness), asthma, schizophrenia, hypertension, and heart disease.Record review of Resident #79's face sheet revealed a [AGE] year-old female who readmitted to the facility on [DATE]. Her diagnoses included in part, dementia, psychotic disturbance, anxiety, multiple sclerosis (an autoimmune condition that affects your brain and spinal cord), and hungry bone syndrome (a condition that causes low calcium levels in the blood after parathyroid or thyroid surgery or metastatic prostate cancer).In an observation and interview on 7/29/25 at 11:53 a.m. of the meal cart on the 300-hallway revealed Resident #48's breakfast tray was on the top rack and contained a half empty cup of red juice, a spoon in a bowl and a covered plate. Items on the tray appeared to be eaten ( dirty). Resident #79's lunch tray was below Resident #48's breakfast tray and appeared to be untouched ( clean). There were plastic tops on Resident #79's beverages and a cover on the plate and bowls. Resident #79's meal ticket and plastic juice lid were soiled with red juice. Red juice also appeared to be spilled on the side of the meal cart rack and on Resident #48's breakfast tray. CNA H said she just picked up Resident #48's breakfast tray and juice from the tray spilled over on other trays. She said Resident #79 had not received her lunch tray yet. CNA H removed the juice from Resident #79's lunch tray and delivered the remainder of the tray to Resident #79. She said she would replace the juice. She said she knew not to put the dirty tray right next to the clean tray. She said she honestly did not know if a dirty tray could be placed above the clean tray and was not told that would be an issue. In an observation and interview on 7/29/25 at 12:00 p.m. of Resident #11 in her room revealed she was eating her lunch. Her tray, meal ticket, and butter container were soaked with juice. CNA H said the juice from Resident #48's breakfast tray also spilled on Resident #11's tray and she tried to clean it up. In an interview on 7/29/25 at 12:50 p.m. ADON D said dirty and clean trays should not be placed together on the cart. She said CNA H informed her she messed up and put a dirty tray on top of a clean tray and contents from the dirty tray spilled. ADON D said that could be an infection control issue and residents could be at risk of an unknown virus. She said the DON and ADON conducted infection control in services, including meal tray service, all the time. In an interview on 7/29/25 at 3:53 p.m. the DON said she expected staff to remove the trays after breakfast. She said there should not be used trays stored with clean food due to infection control issues and cross contamination. She said the facility trained staff a lot on infection control.Record review of the facility's Nutrition Policies and Procedures dated 6/20/23 read in part, .meal delivery . Procedures: .13. Do not return trays to the tray delivery cart until all unserved trays have been passed .

Based on observations, interviews, and record review, the facility failed to ensure residents had the right to a safe, clean, comfortable and homelike environment for 2 of 23 residents (Resident #27, Resident #14) reviewed for environmental concerns. - The facility failed to ensure the wall in Resident #27's bedroom wall was repaired when the sheetrock was damaged.- The facility failed to ensure the air conditioning unit in Resident #14's bedroom was free of dirt and debris. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe. The findings included: In an observation in Resident #27's room on 7/30/25 at 10:47am, the wall behind Resident #27's bed had sheetrock damage that was streaked, about 10 inches long. The streaks were white, and the wall was painted blue. There was sheetrock dust behind the bed on the floor. In an observation and interview in Resident #14's room on 7/31/25 at 12:21pm, Resident #14 said she had mold in her air conditioning vent. Her unit was located underneath the window in her room through the wall. There were multiple small, fuzzy white patches. Some were round and some were abnormally shaped. They were located in the airflow grate. In an interview on 7/31/25 at 12:25pm, the Maintenance Assistant said he was aware of sheetrock damage behind some of the residents' beds. He said they had to add sheetrock to the wall, patch it and repaint it. He said they were notified by the Admissions Director when a room was vacant and could be repaired. He said it had been a while since they completed maintenance rounds. In a telephone interview on 8/2/25 at 12:44pm, the Maintenance Director said the sheetrock damage was due to the residents or staff pushing the beds against the wall. He said the repair required too much work to fix it while the room was occupied. He said they wait until a resident moved out to fix the sheetrock. When asked about the air conditioning unit in Resident #14's room, he said he was notified by Resident #14 and they cleaned it yesterday. He said they pulled the vent off and used bleach wipes to remove the debris. He said most of it was dirt from the outside that built up on the grates. Record review of a facility policy for the Resident Right for Environment That Preserves Dignity dated 11/1/17 read in part, The facility staff will provide the patient/resident with the right to an environment that preserves dignity and contributes to a positive self-image.Facility Staff. creates a home-like environment for the patient/resident that includes.clean, orderly, comfortable, and safe environment.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for Resident #1. The facility failed to update Resident #1's care plan to reflect she was a two plus person physical assist that resulted in an improper transfer on 07/15/2025. This led to Resident #1's, left shoulder fracture. An immediate jeopardy (IJ) was identified on 07/20/2025. The IJ template was provided to the facility on [DATE] at 10:39 am by the Investigator. While the IJ was removed on 07/21/2025, the facility remained out of compliance at a scope of isolated with a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed dependent residents at risk of being injured, bruised, or have fractured limbs. Findings include: Record review of Resident #1's face sheet revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: Personal history of traumatic brain injury (Primary, Admission), Pain disorder with related psychological factors, Acute pain due to trauma, Pain disorder exclusively related to unsteadiness on feet, Cognitive communication deficit, need for assistance with personal care, other abnormalities of gait and mobility, Idiopathic gout, (a digestive disease-herat-burn) right ankle and foot, Muscle weakness (generalized), Conversion disorder with seizures or convulsions. Record review of Resident # 1's nurses notes, dated 07/15/2025, revealed Nurse A notified Resident # 1 primary Physician of the popping sound. The Dr. ordered a STAT x-ray to the left shoulder and upper arm. Nurse # 1 said she ordered the STAT x-ray with a local X-ray company. The x-ray revealed a left shoulder mild displaced fracture of the proximal humerus (a break in the upper arm bone near the shoulder joint) surgical neck. The Dr. gave orders for the Resident# 1 to be sent out to the hospital for further evaluation and a higher level of care. Resident was sent out by the night nurse. The Hospital x-ray revealed the same proximal humerus fracture. Record review of Resident #1's care plan, effective date 12/06/2024, revealed the resident the Resident requires a Hoyer lift with 2 staff for transfer. Further review revealed resident was at risk for falls related to unsteady gait. Revised on 7/17/2025 Record review of Resident # 1's MDS dated , 06/06/2025, revealed section C0500-BIMS coded as an 11 which indicated moderate cognition impairment. Section G-transfer revealed Resident # 1 depended totally on staff to move to or from between surfaces; bed, chair, wheelchair and standing, with two plus persons' physical assist. Record review of Resident #1's care plan with effective date of 12/6/24 revealed Resident #1 required 1-2 person(s) assist with transfers. Last revised on 5/5/25. During an interview with Nurse A on 07/18/2025 at 11:07 am, she stated she was at the nursing station documenting around shift change when CNA D came and asked her to come with him. Resident # 1 was still sitting in her wheelchair. CNA D said during the transfer, he attempted to pivot Resident #1 back into her bed when he heard a popping sound on Resident # 1's left shoulder, and the Resident was crying. Nurse A stated she did not review the care plan to know how many staff were required currently to assist Resident # 1 during transfers. Nurse A stated she assessed Resident #1 and gave her pain medication. During an interview with CNA D on via telephone on 07/18/2025 at 11:47 am, he stated he walked into Resident # 1's room and remembered she was a 1 person assist from the last time he checked the POC. He stated, he did not check the portion of the POC that would have showed if she was a one or two person assist, so he did not request for assistance. CNA D said, Resident # 1 was begging to be put back into bed. CNA D told the Resident; the mechanical lift was not working because the battery was not charged. CNA D in attempting to pivot Resident #1 back to her bed, he heard a popping sound from the resident's left shoulder. During an interview with Resident #1 on 07/18/2025 at 3:23 pm over the phone, she stated CNA D was trying to put her in bed by himself without using a mechanical lift. She stated CNA D did not tell her that, the mechanical lift was not working because the battery was not charged. Resident #1 said, she asked CNA D; Would you please use the Hoyer Lift, he said no. I can pick you up by myself. Resident #1 said, when CNA D picked her up from under her arms, she heard a popping sound from her left shoulder and started crying. Resident # 1 said when the nurse arrived at her room about 20 minutes later, she told the nurse CNA D picked her up in the wrong way, and her left arm popped. Resident #1 said, the nurse gave her pain medication on that day. Resident # 1 said In the past, it's been two staff helping to transfer me. This one decided not to use the Hoyer lift on Tuesday night.During an interview with the ADON on 07/21/2025 at 10:11 am, she stated updating the care plan to reflect the needs of the residents was the responsibility of all nurse managers, but the MDS coordinator was predominately over the care Plan. The ADON stated she did not know why Resident # 1's care plan was not updated prior to the incident. During an interview with the Administrator on 07/21/2025, at 11:43 am, he stated: I did not realize there was a discrepancy between the care plan and the MDS. During an interview with the Administrator on 07/20/2025 at 1:57 pm, the Administrator stated the MDS, and the Care Plan information should match. He said on the MDS if there is a 7 day look back period for transfer and there are 2 days where the transfer level required a higher level of assistance for the rest for the week, that is what is going to be coded on the MDS. He said the MDS will capture the highest level of assistance, and the care plan will capture the lowest. That is why Resident # 1's care plan and MDS do not match. During an interview with the DON on 07/21/2025, she stated it was the responsibility of the Director of Nursing, Assistant Director of Nursing, wound care nurse and MDS nurses to update care plans. The DON stated it was updated quarterly or when an incident occurred. During an interview via telephone on 07/19/2025 at 11:31 am with the MDS coordinator, she said assessments were done quarterly-every 3 months. She stated if a resident's care changed to hospice care, a new assessment was completed, and the care plan would be updated. The MDS coordinator said, the care plan and MDS should match. The MDS which had what was charted, and the care plan had the same information. The MDS coordinator was not on site. The facility's MDS policy revised on 05/05 2023 revealed: -Complete a comprehensive significant assessment as soon as needed to provide appropriate care to the individual. -A significant correction is completed when the MDS or care plan does not suit Residents' needs.On 07/20/2025 at 10:39 am., an Immediate Jeopardy was identified. The Administrator was provided with the IJ template on 07/20/2025 at 10:39 am and Plan of Removal (POR) was requested at that time. The POR summited by the Administrator was accepted on 07/20/2025 at 10:17 am. The POR revealed: Immediate Jeopardy, Plan of Removal 07/21/2025 at 11:34 am.F656 Develop/Implement Comprehensive Care Plan The facility failed to develop and implement a comprehensive person-centered care plan for Resident#1, which included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs.Identified resident is being transferred using 2-person mechanical lift transfer per updated resident's plan of care. Resident #1's care plan and care profile were updated to reflect 2-person mechanical lift transfer on 7/17/25 by the Director of Nursing/Designee. Investigator observed Resident #1 during a transfer with 2 staff. The facility record reviewed by the Investigator revealed, Certified Nursing Assistant D no longer employed at facility. Last day of employment was 7/17/25 due to violation of rules and policies. Mechanical lifts in the facility were examined for proper functioning and operation including batteries on 7/18/25 at 12:15 pm by the Maintenance Director/designee. Facility record reviewed by the Investigator revealed, Licensed nurses and certified nurse aides were re-educated by Rehab Director/Designee by 7/18/25 on the following: Identifying changes to resident's activities of daily living assistance required and reporting to nurse/nurse management to update the plan of care. Accessing point of care profile of the resident to confirm assistance needed for activities of daily living Facility records reviewed by the Investigator revealed Licensed Nurses and certified Nurse aides had 2-person competency checks completed by the director of Nursing/Designee by 7/19/25. Nursing Staff not receiving the education or completing the competency by 7/19/25 will receive prior to their next scheduled shift. The Administrator, Director of Nursing and Nurse Assessment Coordinators were reeducated by the Clinical Consultant on comprehensive person-centered care plans including that the care plan and MDS should reflect the residents current transfer status on 7/20/25. Change in status needs will be discussed three times a week during nurse aide meeting. The Director of Nursing/Designee during this meeting will review the identified resident's profile and care plan to validate changes in assistance have been updated. Completed MDS will be reviewed in clinical morning meeting to validate current transfer status is reflected in the care plan and care profile Monday - Friday by the Director of Nursing/Designee. The Director of Nursing/Designee will randomly observe 3 certified nursing assistants performing transfers three times weekly to validate transfers are following the residents' plan of care. Resident's will be reviewed quarterly following the MDS schedule and as needed with changes of condition daily during the clinical meeting review to validate current transfer status matches the care plan and care profile by the Director of Nursing/Designee. The administrator will validate reviews in clinical morning meeting and review transfer observations to validate appropriate actions are taken to safeguard the residents. This was verbalized during a morning meeting. The Administrator stated the medical director was notified of the immediate jeopardy on 7/20/2025 by the administrator.An Ad Hoc (A meeting called to address specific quality issues) Quality Assurance Performance Improvement meeting was held on 7/20/2025 regarding the contents of this plan. Monitoring of the Plan of Removal included: Following acceptance of the facility's plan of removal, the facility was monitored from 07/20/2025 at 10:39 am to 07/21/2025 at 11:34 am. The Investigator confirmed the facility implemented their plan of removal sufficiently from 07/20/2025 to 07/21/2025. Record review, Resident #1's care plan was updated to reflect 2 persons transfer with a mechanical lift on 07/17/2025 by the DON. CNA D was terminated on 07/17/2025 due to violation of rules and policies. Record review of facility's records revealed, nurses and certified nurse assistants were re-educated on:-Identifying changes to Residents'' activities of daily living assistance requirements and reporting to nursing management to update care plan.-Nurses and CNAs to identify point of care profile of the residents to confirm assistance is needed. Nursing staff had competency checks from 07/18/2025 to 07/19/2025 with signatures. Record Review of facility's record revealed: Change in status will be discussed 3 times a week during Nurse Aides meetings. The DON/designee during these meetings will review the identified Residents' profile and care plan to validate changes in assistance have been updated. Interview with the facility Administrator on 07/21/2025 at 11:43 am, revealed the care plan was updated to reflect Resident # 1's current assistance needs. The Administrator, Regional Clinical Consultant, DON, ADON and the Medical Director, were informed the Immediate Jeopardy was removed on 07/21/2025 at 11:34 am. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review, the facility failed to ensure each resident received supervision and assistive devices to prevent accident for Resident #1. On 07/15/2025, CNA D transferred Resident #1 unassisted using a stand and pivot method instead of a mechanical lift (a device used to aid in the transfer and movement of individuals especially those with mobility limitation) device as required by her care plan dated 12/06/2024. During the transfer there was audible pop from Resident #1's left shoulder. Resident #1 had pain and sustained a fracture. An immediate jeopardy (IJ) was identified on 07/18/2025. The IJ template was provided to the facility on [DATE] at 05:34 pm. While the IJ was removed on 07/20/2025, the facility remained out of compliance at a scope of isolated with a severity level of potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. This failure placed dependent residents at risk of experiencing pain, injuries, bruises, and fractures from possible accidents which could result in a diminished quality of life and hospitalization. Findings include: Record review of Resident #1's face sheet revealed, a [AGE] year-old female who was admitted to the facility on [DATE]. The resident's diagnoses included: Personal history of traumatic brain injury (Primary, Admission), Pain disorder with related psychological factors, Acute pain due to trauma, Pain disorder exclusively related to unsteadiness on feet, Cognitive communication deficit, Need for assistance with personal care, other abnormalities of gait and mobility, Idiopathic gout (A digestive disease-heart burn), right ankle and foot, Muscle weakness (generalized), Conversion disorder with seizures or convulsions (Violent , uncontrollable shaking of the body). Record review of Resident # 1's MDS dated , 06/06/2025, revealed section C0500-BIMS codes as an 11 which indicated moderate cognition impairment. Section G-transfer revealed Resident # 1 depended totally on staff to move to or from between surfaces; bed, chair, wheelchair and standing, with two plus persons' physical assist. Record review of Resident #1's care plan, dated 12/06/2024, revealed the Resident required a mechanical lift with 2 staff for transfer. Further review revealed resident was at risk for falls related to unsteady gait. Record review of Resident # 1's nurses notes, dated 07/15/2025, revealed Nurse A notified Resident # 1 primary Physician of the popping sound. The Dr. ordered a STAT x-ray to the left shoulder and upper arm. Nurse # 1 said she ordered the STAT x-ray with a local X-ray company. The x-ray revealed a left shoulder mild displaced fracture of the proximal humerus (a break in the upper arm bone near the shoulder joint) surgical neck. Nurse A stated, the Dr. gave orders for Resident# 1 to be sent out to the hospital for further evaluation and a higher level of care. Resident was sent out by the night nurse. The Hospital x-ray revealed the same proximal humerus fracture. Observation of the mechanical lift storage room on 07/18/2025, at 10:25 am revealed there were three mechanical lifts and a battery charging unit that could hold three mechanical lift batteries. Two of the mechanical lifts had fully charged batteries while the third battery was on the battery charging unit. During an interview with Nurse A on 07/18/2025 at 11:07 am , said, she was at the nursing station documenting around shift change when CNA D came and asked her to come with him. Resident # 1 was still sitting in her wheelchair. CNA D said during the transfer, he attempted to pivot Resident #1 back into her bed when he heard a popping sound on Resident # 1's left shoulder, and the Resident was crying. Nurse A stated she did not review the care plan to know how many staff were required currently to assist Resident # 1 during transfers. Nurse A stated she assessed Resident #1 and gave her pain medication. During an interview with CNA D via telephone on 07/18/2025 at 11:47 am, he stated he walked into Resident # 1's room and remembered Resident #1 was a 1 person assist from the last time he looked at the POC. He did not check the portion of the POC on the day of the incident that would have showed if she was a one or two person assist, so he did not request for assistance. CNA D said, Resident # 1 was begging to be put back into bed. CNA D told the resident the mechanical lift was not working because the battery was not charged. CNA D in attempting to pivot Resident #1 back to bed, he heard a popping sound from Resident #1's left shoulder. During an interview with Resident #1 on 07/18/2025 at 3:23 pm over the phone, she stated CNA D was trying to put her in bed by himself without using a mechanical lift. She stated CNA D did not tell her that, the Mechanical lift was not working because the battery was not charged. Resident #1 said, she asked CNA D, Would you please use the mechanical Lift, he said, no. I can pick you up by myself. Resident #1 said, when CNA D picked her up from under her arms, she heard a popping sound from her left shoulder and started crying. Resident # 1 said when the nurse arrived at her room about 20 minutes later, she told the nurse CNA D picked her up in the wrong way, and her left arm popped. Resident #1 said, the nurse gave her pain medication on that day. Resident # 1 said; In the past, it's been two staff helping to transfer me. This one decided not to use the mechanical lift on Tuesday night. During an interview with the DON on 07/18/2925 at 12:49 pm, she said transfers were covered during orientation, which include the use of gait belt and mechanical lift. The DON stated inappropriate transfers, could cause injury, bruising, skin tears, a fall, a fracture, dislocation and abrasions. The DON stated, delayed treatment could cause further injury or harm to the resident. The DON stated she was notified of Resident # 1's incident. The DON stated, the CNAs had a profile on the computer where they documented and saw what assistance was needed by the residents. During an interview with the Administrator on 07/18/2025 at 2:37 pm, he stated CNA D disclosed what happened to the DON. The Administrator stated CNA D was terminated on 07/17/2025 for completing an improper transfer with Resident #1. The Administrator stated an inappropriate transfer, could lead to injuries of the Resident or the staff. He said it was inappropriate transfer that led to Resident # 1's left shoulder fracture. Fracture. During an interview with the Maintenance Director on 07/18/2025 at 3:05 pm, he stated staff told him the mechanical lift battery charger was not working. He stated he got a new battery, and it started working. He stated that was roughly about 3 months ago. Record review of facility's residents' rights policy revised on 06/09 2023 revealed: The facility must provide equal access to quality care regardless of diagnosis, and severity of condition. A record review of the facility's mechanical lift policy, revised on 05/05/2023, revealed: Mechanical lifts may be used for enhanced safety of patients, residents in situations including but not limited to:-Lifting from the floor-Bed to chair-Lateral transfer-Toileting and bathing-Repositioning.-Sitting or lying-to stand Prior to initiating the use of a mechanical lift for a patient or resident: Determine how many caregivers are necessary to safely lift the patient or Resident. In most cases and for safety, a minimum of 2 caregivers is recommended. Evaluate the resident's medical stability. On 07/18/2025 at 05:34 pm., an Immediate Jeopardy was identified. The Administrator was provided with the IJ template on 07/18/2025 at 05:34 pm, and a Plan of Removal (POR) was requested at that time. The POR summited by the Administrator was accepted on 07/19/2025 at 07: 29 am. The POR revealed: Crimson Heights Health and Wellness, Immediate Jeopardy, Plan of Removal, 07/20/2025 at 09:37 am.F689 Free of Accident Hazards/Supervision/Devices. The facility failed to safely transfer Resident #1 when CNA D performed a two person transfer alone using a stand and pivot method instead of a full Hoyer lift when resident persistently asked to be put in bed. Identified resident is being transferred using 2-person Hoyer transfer per updated resident's plan of care. Resident #1's care plan and care profile were updated to reflect 2 person Hoyer transfer on 7/17/25 by the Director of Nursing/Designee. Certified Nursing Assistant D no longer employed at facility. Last day of employment was 7/17/25 due to violation of rules and policies. An audit was completed by the Director of Nursing/designee validating residents transfer status, including residents that require 2 person Hoyer lift with current orders, profiles, and care plans by 7/19/25. No discrepancies identified. Mechanical lifts in the facility were examined for proper functioning and operation including batteries on 7/18/25 at 12:15 pm by the Maintenance Director/designee. Licensed nurses and certified nurse aides were re-educated by Rehab Director/Designee on 7/18/25 on the following: Identifying changes to resident's activities of daily living assistance required and reporting to nurse/nurse management to update the plan of care. Accessing point of care profile of the resident to confirm assistance needed for activities of daily living Licensed Nurses and certified nurse aides will have 2-person competency checks completed by the Director of Nursing/Designee by 7/19/25. This was verified by the investigator. Nursing Staff not receiving the education or completing the competency by 7/19/25 will receive prior to their next scheduled shift. The Director of Nursing/Designee will randomly observe 3 certified nursing assistants performing transfers three times weekly to validate transfers are following the Resident's plan of care. This was verified by the investigator. Residents' will be reviewed quarterly following the MDS schedule and as needed with changes of condition daily during the clinical meeting review to validate accurate transfer status is included in the care plan and care by the Director of Nursing/Designee. New admissions and re-admissions will be reviewed daily in clinical morning meeting to validate transfer status included in the care plan and care profile is accurate. The weekend supervisor will validate care plans and care profile accuracy of transfer status on the weekend. There were no new admissions for the Investigator to observe. The Administrator will validate reviews in clinical morning meeting and review transfer observations to validate appropriate actions are taken to safeguard the residents. The Administrator verbalized this statement to the Investigator The medical director was notified of the immediate jeopardy on 7/18/2025 by the administrator.An Ad Hoc (A meeting called to address a specific issue) Quality Assurance Performance Improvement meeting was held on 7/18/2025 regarding the contents of this plan. Monitoring of the plan of removal included: Following acceptance of the facility's plan of removal, the facility was monitored from 07/18/2025 from 05:34 pm to 07/20/2025 at 09: 37 am. The Investigator confirmed the facility implemented their plan of removal sufficiently from 7/17/2025 to 07/20/2025 to remove IJ by: Record review of the facility completed reeducation from 07/17/2025 to 07/19/2025 on all-certified nurse assistants, completed by the ADON. The perpetrator, CNA D was terminated on 07/17/2025 due to violation of rules and policies. Resident # 1's care plan was updated to reflect 2-person mechanical lift transfer. Nurses and certified nurse assistants had two competency checks from 07/18/2025 to 07/19/2025 Observation of two CNAs on 07/18/2025 at 10:04 am, revealed they completed successful mechanical lift transfers from bed to wheelchair and wheelchair to bed. Observation of the storage room on 07/18/2025 at 10: 25 am revealed 3 mechanical lifts, and 2 of them had a fully charged battery. The third mechanical lift's battery was in the battery charging station. Observation on 07/18/2025 at 12:15 am, revealed all mechanical lift devices in the facility were examined for proper functioning and operation, including batteries and 07/18/2025 by Maintenance Director. Interviews were conducted with CNAs and nurses from 07/18/2025 at 10:04 am to 07/19/2025 at 10:57 pm ; CNA A,CNA C,CNA E, LVN A, CNA F, CNA F, LVN B, CNA G, LVN C, CNA H, CNA B, LVN D, RN A, CNA I, and CNA J, revealed they were reeducated on the use of mechanical lift and gait belt. The Administrator, DON, ADON, and Regional Clinical Consultant, Medical Director were informed, the Immediate Jeopardy was removed on 07/20/2025 at 09:37 am. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated as the facility continued to monitor the implementation and effectiveness of their plan of removal.

Based on observation, interview, and record review the facility failed to ensure all patient care equipment was in safe operating condition for one (Resident #1) of five residents reviewed for safe operating patient care equipment. The facility failed to ensure Resident #1 had a functioning toilet. This failure could place residents at risk of unsanitary conditions. Findings included: Record review of Resident #1's face sheet dated 6/18/25 revealed a [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis included age-related cognitive decline, cellulitis (bacterial infection of the skin) of left lower limb, pain disorder, and cerebral infarction (stroke). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 11 out of 15 which indicated moderate cognitive impairment. He was always continent of bowel and bladder and required assistance from staff with toileting hygiene and toilet transfers. Record review of Resident #1's care plan edited 5/23/25 indicated he required assistance with ADL's, the approach included toileting with assist of independent. His care plan also indicated he had periods of socially inappropriate and verbal aggression. Resident #1 had a preference of using bags and bed pans to defecate and urinate in rather than use the toilet, dated 6/17/25. In an interview and observation on 6/17/25 at 9:21 a.m. in Resident #1's room revealed the sound of running water coming from the toilet. The toilet was not in use. The Surveyor attempted to flush the toilet and it would not flush. Resident #1 said his toilet had not been working since March (2025). He said he used a urinal and a bed pan and had to dispose of his urine and feces in his trash can because his toilet did not work. He said he did not want the staff to dispose of the urine and feces in his shower or sink. He said he informed the Receptionist and Maintenance Director that his toilet was not working (unknown date). In a telephone interview on 6/17/25 at 11:19 a.m. Resident #1's family member said the resident's toilet did not work and staff complained because he used his trash can for his bodily waste. In an observation and interview on 6/17/25 at 1:06 p.m. revealed CNA R attempted to flush Resident #1's toilet and it would not flush. She said the resident used the toilet this morning and it was working. She said Resident #1 used a bedpan and urinal and she would empty his urine in his toilet. She said she would report the non-working toilet. In an interview on 6/17/25 at 2:37 p.m. the Administration Assistant said Resident #1 informed her he had concerns with the toilet in his bathroom on an unknown date. In an interview on 6/17/25 at 4:52 p.m. the Maintenance Director said he was not aware that Resident #1's toilet was not flushing. He said the Assistant Maintenance primarily repaired toilets. In an observation and interview on 6/17/25 at 5:18 p.m. the Assistant Maintenance attempted to flush Resident #1's toilet but it would not flush. He said no one informed him that Resident #1's toilet was not working. He said to his knowledge the toilet was flushing previously and the aide said the resident did not use the toilet. He said he would have to notify the Maintenance Director about the toilet. In an interview on 6/17/25 at 5:25 p.m. CNA L said she was unsure if Resident #1's toilet was flushing properly. She said sometimes it flushed properly but other times the water would go down slowly. She said Resident #1 disposed of his waste in his trash can. In an interview on 6/17/25 at 5:40 p.m. the Administrator said he expected residents' toilets to function properly and for the Maintenance Director to address any problems. He said Resident #1's toilet not working was new and was not on the maintenance log. Record review of the facility's Maintenance Log for June 2025 revealed Resident #1's toilet was flushing slowly on 6/17 and was resolved on 6/17. Record review of the facility's Maintenance/Housekeeping - Routine Maintenance policy dated 3/2006 reflected in part, . the center performs routine maintenance on floors, walls, fixtures and equipment . Record review of the facility's Maintenance/Housekeeping - patient/resident room checklist policies and procedures dated 7/26/2017 reflected in part, . toilet . flush toilet to ensure adequate flow .

Based on observation, interview, and record review, the facility failed to ensure that residents received the necessary treatment and services, to promote healing, prevent infection for 1 of 5 residents (Resident #1) reviewed for pressure ulcers in that: -The facility failed to ensure Resident #1's right buttock stage 2 pressure wound had a dressing covering the wound on 12/04/2024. This failure could affect residents with wounds placing them at risk of infection, a decline in health, pain, and hospitalization . Findings included: Record review of Resident #1's (undated) face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included muscle weakness (occurs when your muscles are unable to contract properly, resulting in reduced strength), hypotension (a condition where the force of blood pushing against artery walls is lower than normal) and pain ( a sensory and emotional experience that can be unpleasant and distressing). Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score 07 out of 15 which indicated she had severely impaired cognition. She required partial/maximal assistance with toileting hygiene, shower/bathe self, and personal hygiene. H0300 Urinary continence coded: always incontinent of bowel and bladder. Section M0150 Resident was at risk for developing pressure ulcers/injuries. Record review of Resident #1's care plan initiated 10/27/2024 and revised on 12/03/2024 revealed the following: Problem: (Resident#1) has a Stage II pressure ulcer on her Right Buttock related to [X] immobility, [X] incontinence, [] poor nutrition, [] decreased cognition, [] diabetes, [] heart failure, [] COPD, [] kidney failure Goal: Resident's ulcer will decrease in size and will not exhibit signs of infection as evidenced by wound documentation for 90 days. Interventions: CNAs to inspect skin, especially over bony prominences, during bathing and personal care and report findings to Licensed Nurse. Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage by cleaning with mild cleansing agents and using skin barrier cream for skin protection. Record review of the Physician's orders for Resident #1 dated 12/03/2024 revealed an order to cleanse stage ll pressure injury with WC/NC, pat dry, apply collagen then cover with a bordered gauze dressing daily & Prn if soiled or dislodged. Observation and attempted interview on 12/04/24 at 9:53 a.m., revealed Resident #1 was resting on an air mattress. She was alert and well groomed. The resident mumbled for 5 minutes while being interviewed and could not make herself understood and did not respond appropriately to asked questions about her pressure sore/injuries. Observation on 12/04/24 at 9:59 a.m., revealed the Wound Care Nurse providing wound care for Resident #1. The Wound Care Nurse was assisted by CNA A. An open area of approximately 2.0 centimeters in diameter, was observed without a dressing on the right buttock. The Wound Care Nurse said, Hospice aide just gave bed bath to the resident. She might have taken the dressing off. In an interview on 12/04/24 at 10:09 a.m., with the Wound Care Nurse, he confirmed Resident #1's right buttock wound did not have a dressing on it. When asked how do the hospice aides know who to report these type of concerns to, and who is responsible for monitoring these aides when they are in the building, the WCN said the hospice aide should have immediately notified him or the floor nurse because there were prn orders if the dressing became soiled or dislodged. The WCN stated it was important to provide dressings on the wound to keep it protected from infections. In an interview on 12/04/24 at 10:21 a.m., with LVN ZZ, she stated the CNA, or the hospice aide did not notify her that Resident #1's dressing had come off. She said the aides were supposed to come and tell the nurses right away so the nurse can dress the wound as there were prn orders for dressing change. In an interview on 12/04/24 at 1:53 p.m., the ADON stated the Wound Care Nurse was responsible for wound care Monday through Friday. The Surveyor shared the observation from earlier. The ADON said her expectation was for wound dressings to be changed daily and as needed if soiled or dislodged according to physician's orders. When asked how do the hospice staff know who to notify and when they should be notified, the ADON stated she was going to get with hospice company so they could educate their staff. ADON stated the hospice aide should have notified the floor nurse/wound care nurse so they could dress the wound . She stated it was important to dress the wound to prevent infection. She stated Resident#1 was incontinent of bowel/bladder feces could get in and the wound could get worse. Record review of the facility's Wound Care policy dated (Revision: 6/1/2015) revealed read in part: . subject: Pressure ulcers. Policy: Pressure ulcers will be evaluated and treated in accordance with professional standards of practice to heal and prevent pressure ulcers unless clinically unavoidable . Record review of the facility's Wound Care policy dated (6/1/2015) revealed read in part: . subject: Performing A Dressing Change. Policy: A dressing change will follow specific manufacture's guidelines and general infection control principles. 6. Apply a cover dressing-date and initial cover dressing, place time reference on it .

47772 Based on observations, interviews, and record reviews, the facility failed to assist with activities of daily life, for 2 of 8 residents (Resident #50 and Resident #98) who was observed for assistance with ADLs. The facility failed to: - Provide supervision, or touching assistance, for Resident #98 during food service. - Answer Resident #50's call light for 50 minutes after repeated verbalizations/request for help as he was soiled with urine and bowel movement subsequently making him feel helpless and neglected. This failure placed residents at risk of poor nutrition, dehydration, skin breakdown, and unintended weight loss. Findings included: Resident #98 Record review of Resident #98's face sheet, dated 6/12/2024, reflected Resident #68 was a [AGE] year-old-male, who admitted to the facility on [DATE]. He was diagnosed with Acquired Absence of Left Leg Above Knee (which was an amputated extremity,) Type 2 Diabetes (which was a problem of the body's ability to use sugar for fuel,) Moderate Protein Calorie Malnutrition (which was a diagnostic code for nutritional metabolic disease,) and Other Symptoms and Signs Concerning Food and Fluid Intake (which was a diagnostic code nutrition deficiency.) Record review of Resident #98's Admission MDS assessment, dated 5/28/2024, reflected Section C., Cognitive Patterns; Indicated Resident #98 had a BIMS Score of 5. A BIMS Score of 5 indicated Resident #98 had severe cognitive impairment. Section GG., Functional Abilities: Indicated Resident #98 required supervision or touching assistance while eating. Supervision or touching assistance meant the helper provided verbal cues and/or touching, steadying and/or contact guard assistance as the resident completed the activity. Assistance may have been provided throughout the activity, or intermittently. Resident #98 required partial/moderate assistance rolling left to right; sitting to lying; and lying to sitting on bed. Partial/moderate assistance meant the helper did less than half of the work completing the task. Record review of Resident #98' CP indicated a problem area, created 6/10/2024, for ADLs evidenced by the need for required assistance. The goal, created on 6/10/2024, indicated Resident #98 would improve ADL independence. The intervention for nursing staff, created 6/10/2024, indicated Resident #98 would require 1 staff member with bed mobility and 1 staff member with eating. Record review of Resident #98's general nursing order, dated 5/24/2024 and written by ADON B, indicated Resident #98 would receive assistance of 1 person while eating. Record review of Resident #98's weights indicated on 05/24/2024, the resident weighed 95.1 lbs. On 06/12/2024, the resident weighed 94.6 pounds which is a -0.53 % Loss. Interview on 6/11/2024 at 10:54 AM with Resident #98 revealed he had not been able to eat like he wanted. He took his meals in his room and stated the CNAs, who served him his meals, did not take time to feed him. He stated they brought him his meals, set up his tray, and then went on to the next person. Observation on 6/12/2024 at 12:04 PM reflected CNA D entering Resident #98's room to deliver his lunch. Observation on 6/12/2024 at 12:08 PM reflected CNA D exiting Resident #98's room after delivering his lunch. Observation and interview on 6/12/2024 at 12:08 PM reflected Resident #98 in his bed with this bed raised between 30 to 45 degrees. His lunch was on a bed side table positioned across his mid-section. His milk was opened, soup was uncovered and in front of him, his main dish was at the back of the tray still covered. His beverage still had the lid. Interview with Resident #98 revealed CNA B brought him the tray, set it up a little, and she said she would be back later to see if he needed any help. Observation on 6/12/2024 at 12:14 PM reflected the CNA D had not returned to the room. Observation on 6/12/2024 at 12:26 PM reflected the CNA D had not returned to the room. Observation and interview on 6/12/2024 at 12:36 PM of Resident #98's food tray reflected a small percentage of his lunch had been consumed. Interview revealed he was unable to eat his entire lunch because of his limited mobility and not being able to re-position his body. Interview and observation on 6/13/2024 at 1:53 PM with CNA D revealed there were residents on the hallway that required the assistance of 1 person while eating. She stated those residents were identified through shift change or by looking on the kiosk, which was a computer monitor mounted on the wall, which indicated the ADL care required. CNA D was observed having logged on the kiosk and having searched residents who required X 1, an additional, person for eating assistance. CNA D stated that residents, who required X 1 person for eating assistance, were supposed to receive plate set up and actual feeding. Interview and record review on 6/13/2024 at 2:12 PM with LVN G revealed the information which pertained to residents, and the required level of assistance for eating, was determined in the resident assessment, added to the CP, and found on the resident profile. The resident profile was available to the CNAs through the kiosk. LVN G stated that assistance X 1 person assistance for eating required set up, but a requirement to be fed was annotated with a comment, such as the resident needed to be fed. LVN G reviewed Resident #98's resident profile, which indicate eating assistance X 1. She stated there was no annotation having required the resident to be fed. LVN G reviewed Resident #98's assessments. LVN G noted the requirement for required supervision or touching assistance while eating. LVN G stated a resident who did not get their required level of assistance while eating risked weight loss and dehydration. Interview on 06/13/24 at 2:34 PM with the ADON A revealed nursing staff were trained to use the resident profile found in the kiosk to determine their required level of care. There were residents on skilled nursing that needed assistance x 1 for eating. Assistance X 1 person meant the resident needed 1 person in the room while eating for assistance. Safeguards in place to make sure a resident was receiving the required assistance would be thorough chart review, stop, and watch observations, and one-on-one visits. If a resident was not receiving the level of assistance while eating, the resident risked weight loss, dehydration, problems with wound healing, and frustration. Interview on 06/13/24 at 3:48 PM with the ADM revealed he expected his staff to follow facility policy in having aided in ADL care to residents. Residents who required the assistance of 1 person for eating were supposed to have a staff with them to assist set up and provide assistance during the meal. The system in place, to learn of such requirements, was the resident profile. Staff were supposed to refer the resident profile to learn of the required care. Residents who did not get the meal assistance they required were placed at risk of weight loss, thirst, isolation, and frustration. A failure to provide proper assistance for ADL care fell on nursing staff having failed to check the resident profile for required assistance. Record review of the facility's Activities of Daily Living Policy, dated 5-5-2023, indicated ADLs were related to personal care having included grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing, and communication system. Staff were expected to recognize and assess their resident's inability to perform an ADL and review the most current comprehensive or most recent quarterly assessment. Facility staff were supposed to provide assistance to maximize independence including, but not limited to, grooming, dressing, transfer, ambulation, eating, and communication. Resident #50 Review of Resident #50's Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who was admitted to the facility on [DATE] with a BIMS score of 03, indicating severe cognitive impairment. The resident utilized a wheelchair, required supervision with eating, and was totally dependent in the areas of toileting and all transferring. He had diagnoses of dementia, cerebrovascular accident (stroke), hemiparalysis (a common after-effect of stroke that causes weakness on one side of the body), hypertension (when the pressure in your blood vessels is too high (140/90 mmHg or higher) and diabetes. Bowel and bladder care reflected always incontinent. Observation and interview with Resident #50 on 06/12/2024 at 12:45 pm revealed Resident 50's call light was turned on and his door was open. At 1:23 pm Resident #50 yelled out loudly, from his bed, 3 times, I need a change! At 1:28 pm Resident #50 again yelled out loudly, from his bed, 3 times, I need a change! At this time, the surveyor entered Resident #50's room observed him in his bed and asked him if he needed a brief change and if he was both wet and had a bowel movement and Resident #50 said, yes, both. At 1:35 pm, CNA A entered Resident #50's room. After CNA A exited Resident #50's room, surveyor entered his room and asked Resident 50 if his brief had been changed and he said it had been and he was clean. When asked how it made him feel that he was left in a wet dirty brief for 50 minutes he said it made him feel, real bad in a lot of ways and said they could be better. He said it, made me feel like crap and he felt like no one was there to help him and made him feel alone. Interview on 06/11/2024 at 2:25 pm with CNA B revealed staff should respond to call lights as soon as possible and if someone was calling from their room, they should be checked on because something could have happened to the resident. CNA B revealed it is not good resident care for the call light not to be in reach of the resident and a call light should not be located between the back of a bedside table and the wall. CNA B revealed that 50 minutes is too long for a resident to wait for someone to respond to their call light. Interview on 06/11/2024 2:05 pm with CNA A revealed that 50 minutes was too long for a resident to wait for their call light to be answer and residents would feel like their needs were not being meet if they were left in a wet and dirty brief. Interview on 06/13/2024 at 12:18 pm with the DON revealed that call lights should be answered as quickly as possible. She revealed it was not good care for a resident to wait 50 minutes in a wet and soiled brief for it to be changed. The DON revealed it was not good resident care for the resident's call light to be out of reach. She revealed it would not make a resident feel good to sit in a wet soiled brief for 50 minutes and call out for help more than once and for no one to come and help them. It would make the resident feel like no one is listening to them or coming to care for them. Interview on 06/13/2024 at 5:45 pm with the ADM revealed that 50 minutes is not timely for answering a resident call light. He revealed that for a resident to wait that long they could feel isolated, and his call light should have been answered. The ADM revealed a call light should be available and within reach of the resident and each time staff go into a resident's room, they should make sure the call light is in reach. Residents could have had an injury and not be able to get help from the staff if the call light is not in reach. Review of the facility's complaint/grievance report dated 10/26/2023 reflected a grievance that it took too long for staff to respond to the resident's call light. The facility responded to the grievance by stating they would education the staff in answering call lights within a timely manner. Review of facility complaint/grievance report dated 04/19/2024 reflected a grievance that a resident waited 45 minutes to have their call light answered. The administrative staff investigated the grievance and found that it did take 45 minutes for the resident's call light to be answered. Review of facility policy titled Facility Call Lights, Responding To dated 05/05/2023 reflected: Policy - The staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. Procedures: Respond to call lights and requests for assistance as quickly as practicable.

Based on observation, interview, and record review, the facility failed to provide sufficient staff to effectively conduct food and nutrition services for the facility's main dining room. The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth. Findings included: Record review of Resident #66's face sheet, dated 6/12/2024, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #45's face sheet, dated 6/12/2024, reflected an [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #68's face sheet, dated 6/12/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #75's face sheet, dated 6/12/2024, reflected a [AGE] year-old female who admitted to the facility on [DATE]. Record review of Resident #80's face sheet, dated 6/12/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #254's face sheet, dated 6/12/2024, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Record review of the facility's posted meal service reflected breakfast mealtime was 7:00 AM; lunch mealtime was 11:30 AM; and dinner mealtime was 5:00 PM. Observation and record review on 06/11/24 at 11:30 AM, in the facility's dining room, revealed residents beginning to congregate for the lunch meal service. Residents were arriving on their own and residents were being assisted by staff. The meal hours posted on the wall just outside the dining room, indicated lunch service began at 11:30 AM. Observations on 06/11/24 at 12:07 PM, in the facility's dining room, revealed meal service had not begun and the residents had not begun to eat lunch. Interview and observation on 06/11/24 at 12:08 PM with Resident #66 revealed her sitting at a dining room table. Interview with Resident #66 revealed she had been waiting for a long time to be served lunch and she had not been provided with any food. She was very hungry and having to wait for 38 minutes to be served made her feel like she was not thought of as worthy. Interview and observation on 06/11/24 at 12:10 PM with Resident #75 revealed her sitting at a dining room table. Interview with Resident #75 revealed she had been waiting for a long time to be served lunch and she had not been provided with any food. She was very hungry and having to wait for 40 minutes to be served made her feel like she was not valued. Interview and observation on 06/11/24 at 12:12 PM with Resident #80 revealed him sitting at a dining room table. Interview with Resident #80 revealed he had been waiting for a long time to be served lunch and he had not been provided with any food. He was hungry and having to wait for 42 minutes to be served made him feel bad. Observations on 06/11/24 at 12:15 PM, in the facility's dining room, revealed meal service had started to begin. Residents began receiving their meals. The delivery of the meal service was completed at 12:27 PM. Observations and record review on 06/12/24 at 8:14 AM, in the facility's dining room, revealed residents congregated for the breakfast meal service. Residents were seated in the dining room at the tables. Record review of the posted meal hours, posted on the wall just outside the dining room, indicated breakfast service began at 7:00 AM. At the time of the observation, staff were serving residents, but 14 residents had not been provided with their breakfast meal. Interview and observation on 06/12/24 at 8:21AM with Resident #68 revealed him sitting at a dining room table. He had just been approached by staff and served his breakfast meal. Interview with Resident #68 revealed he had been waiting for about an hour to eat. He felt annoyed he had to wait for such a long time. Interview and observation on 06/12/24 at 8:25 AM with Resident #254 revealed him sitting at a dining room table. He had just been approached by staff and served his breakfast meal. Interview with Resident #254 revealed he had been waiting for about an hour to eat. He was angry he had to wait for such a long time. Observation on 6/12/2024 at 8:28 AM of Resident #45 revealed him sitting in his wheelchair at a dining room table. He was observed scooting to the edge of his wheelchair inching towards to the breakfast meal of the resident to his immediate right. There was no breakfast meal in front of him at the time. Both his arms were slightly extended, parallel to the ground, and his hands were moving up and down, at the wrists, like someone would say hello or goodbye. A staff member, CNA C, was observed having re-directed Resident #45 to stay in his seat; Resident #45 received his breakfast meal. Interview on 6/12/2024 at 8:31 AM with CNA C revealed she knew Resident #45 very well. She described his body movements as his way of saying that he was hungry and wanted to eat. Interview on 06/12/24 at 10:27 AM with the DM revealed the facility started serving breakfast at 7:00 AM. The first residents served breakfast were the residents who ate in their rooms on the halls; then, the dining room was served last. The hall trays were sent to the halls beginning at 7:00 AM, where a nursing staff member met the carts and checked the tickets prior to service for the residents. The meals served to the residents on the hallways were completed by 7:30 AM to 7:45 AM. The kitchen, however, would not be able to start serving the residents in the dining hall until a nurse to came to check the tickets and trays for accuracy. The expected time of the nurse's arrival at the dining room was between 7:30 AM and 7:45 AM. The estimated time it took for nursing staff to check the tickets and serve residents in the dining hall was 15 minutes. If the nurse arrived at 7:30 AM, and it took 15 minutes to check tickets and serve the trays, the residents in the dining hall would have waited at their table for 45 minutes for breakfast. If the nurse arrived at 7:45 AM, and it took 15 minutes to check tickets and serve the trays, the residents in the dining hall would have waited at their table for 1 hour for breakfast. The DM stated that the nursing staff did not report to the dining hall between 7:30 AM to 7:45 AM. Furthermore, the kitchen staff would often have to wait an additional 15 minutes for the nurse to arrive to check the tickets and trays. When the nursing staff did not arrive until 8:00 AM, and it took 15 minutes to check tickets and serve the trays, the residents in the dining hall would have waited at their table up to 1 hour and 15 minutes for breakfast. The DM stated the lunch service, which began at 11:30 AM, and how the same method and times were congruent. The DM stated the residents in the dining room had to wait a long time to be served their breakfast and lunch. The DM stated she had addressed the late arrival of the nurse to the dining room, with the ADONs, DON, and the ADM. A schedule was created to address the consistency of the nurse's arrival times, but that schedule had not been effective. At times, the DM stated she utilized the audible paging system for a nurse to report to the dining hall, but that had been ineffective as well. For dinner, all residents were served in their rooms, where the delays did not occur. Interview on 06/12/24 at 10:47 AM with the [NAME] revealed that residents had to wait way to long in the dining hall before they got the chance to eat. The kitchen Staff had to wait for a nurse to check trays, which was supposed to happen between 7:30 AM to 7:45 AM, but they were rarely on time. One time, the kitchen staff had to wait so long, that she had called the DM on her day off for help. The call to her DM was ineffective, meaning the wait was not shortened. She stated that residents had complained, and even described residents as mad. She had observed ambulatory residents (those who could have moved on their own had gotten up and left before meal service had even begun. Observations on 06/12/24 at 11:29 AM reflected 26 residents waiting in dining hall for lunch. Interview on 06/12/24 at 11:54 AM with LVN E revealed she had reported to the dining hall on occasion to check the tickets and trays for residents who ate in the dining hall. She stated there was not a written schedule, but she would usually report to the dining hall about 11:45 AM for the lunch meal. When she would arrive, the dining hall was usually full of residents waiting for their meal. Interview and observation on 06/13/24 at 1:10 PM with LVN F revealed nursing staff reported to the dining hall to check tickets and trays before the meals were served to the residents. She stated the schedule was posted at one time in the staffing folder, but it was not there anymore. LVN F was observed, at the nursing station, looking through the staffing book, but the observation reflected the schedule was not there. Nursing staff had a mutual understanding of who was assigned on which days and which meals. The nurse, who was checking tickets, was supposed to be at the dining hall at 7:00 AM for breakfast and 11:30 for lunch. Interview on 6/13/2024 at 1:22 PM with LVN G revealed she was a nursing staff member who reported to the dining room at times to check tickets for resident's trays. She stated she reported to the dining hall between 7:00 AM and 7:30 AM. The meal service usually took about 15 minutes. If a resident had to wait long to eat, risks they might have faced were being hungry, thirsty, and sometimes angry. Diabetic residents had their blood sugars checked at 6:30 AM. If residents were at risk of low blood sugar, they would have received a small snack, usually orange juice, to combat low blood sugar to tide them over until breakfast. LVN G stated she had been as late as 8:00 AM in reporting the dining hall to check tickets, but those times were rare. Interview on 06/13/24 at 3:08 PM with KA revealed kitchen staff had been instructed to wait for the nurse to come to the dining hall and check tickets before they could start serving the residents. She worked 4 days a week and stated it was quite frequent kitchen staff would have to wait for a nurse, up to 30 minutes past the expected time, to come to the kitchen to proceed feeding the residents in the dining hall. She had observed residents at their tables looking bored, had heard residents calling out for food, had seen residents come to kitchen door to look in the kitchen, and one occasion heard a resident having pounded on the door. Interview on 06/13/24 at 3:23 PM with the ADON B revealed staff started transporting residents to the dining hall for breakfast around 6:45 AM for breakfast at 7:00 AM. Nursing staff usually reported to the dining hall between 7:30 AM to 7:45 AM to check the tickets and the trays before having served the to the residents. According to the times the meals started, and the times nursing staff arrived, residents were having to have waited 45 minutes to 1 hour to have their breakfast. If a resident was placed in a situation to wait at their table for 45 minutes to 1 hour before being served, they risked aggravation for having to wait and confusion as to why they were waiting. Interview on 06/13/24 at 4:07 PM with the ADM revealed he expected his staff to follow facility policy begin serving meals on time. A failsafe in place to identify and correct late meal services was management staff performing observations and ensuring mealtimes were being followed. Risks a resident might face for extended waiting times with meals were general dissatisfactions with the meal service. The failure for residents experiencing delayed meal services would have fallen on the nursing staff reporting to the dining hall on time to perform their duties. Record review of the facility's Meal Service in the Dining Room Policy, dated 6/20/2023, indicated the facility was supposed to serve meals at the times specified/posted.

Based on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Residents #97) reviewed for resident assessments. The facility failed to ensure Resident #97's most recent admission MDS reflected that Resident #97 received dialysis services. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #97's face sheet dated 06/13/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #97's diagnosis included end stage renal disease (a terminal illness that occurs when the kidneys can no longer function properly and support the body's needs; people with ESRD must receive dialysis or a kidney transplant to survive more than a few weeks), hypertension (high blood pressure), Bell's palsy (type of facial paralysis that results in a temporary inability to control the facial muscles on the affected side of the face), and legal blindness (having a central vision acuity of 20/200 or less in your best eye). A record review of Resident #97's Admission MDS assessment, dated 03/29/24, reflected the resident had a BIMS score of 10, which indicated cognition was moderately impaired. Resident #97's Admission MDS reflected Resident #97 had an active diagnosis of renal insufficiency, renal failure, or end stage renal disease (ESRD), and that resident did not receive dialysis services. A record review of Resident #97's care plan, dated 04/10/2024, reflected Resident #97 was care planned for receiving Hemodialysis Due to End Stage Renal Disease. Goal Will not develop complications from dialysis. Approaches: Maintain and encourage resident to go to dialysis. Do not take BP on the arm with shunt. Monitor patency of the shunt by assessing the presence of thrill and bruit, document findings. Weigh resident as ordered. Diet and fluid as ordered. Maintain fluid restriction as indicated. In an interview on 06/12/24 at 11:46 AM, Resident #97 stated she attended dialysis three times a week on Tuesday's, Thursday's, and Saturday's. She stated she had a dialysis port to right arm. She stated the best place to find her if she was not at dialysis would be activities. She stated staff took good care of her and she got to and from dialysis with no problems. She stated she had not had any problems with dialysis. She stated staff checked on her frequently and responded to her quickly when she called for them. She stated she did not have any concerns. In an interview with the DON on 06/13/24 at 12:51 pm, she stated that the MDS nurses were responsible for completing and ensuring the accuracy of the MDS assessments. She stated both of the MDS nurses had been doing the MDS assessments for a long time and she was sure they had been trained on completion and accuracy of MDS assessments. She stated an MDS report should reflect if a resident was receiving dialysis services. She stated she was aware that Resident #97 received dialysis services. She stated she was not aware that Resident #97's MDS assessment did not reflect that resident received dialysis services. She stated if a MDS assessment had not been completed correctly it could affect the care plan because the care plan was triggered by the MDS assessment. She stated if the plan of care was not completed correctly it could have affected the residents care. In an interview with the MDS A on 06/13/24 at 1:17 pm, she stated she and another staff member were responsible for completing the MDS assessments. She stated she was responsible for completing the Medicaid and private pay residents MDS assessments and her partner was responsible for completing the Medicare and skilled care residents MDS assessments. She stated her partner helped her out at times because she had so many. She stated she had been trained on completing and ensuring the accuracy of the MDS assessments. She stated if a resident was receiving dialysis services, the MDS assessment should have reflected it. She stated if a resident admitted to the facility and was receiving dialysis services, it should have been reflected in the admission MDS assessment. She stated if a MDS assessment was completed inaccurately, it could affect the billing and the accuracy, but she felt that it would not have affected the resident because there were many other ways to care for the residents. In an interview with the MDS B on 06/13/24 at 1:27pm, she stated she was responsible for completing the MDS assessments for residents that were on Medicare and skilled services. She stated she and her partner worked together as well. She stated she had been trained on completing and ensuring the accuracy of the MDS assessments. She stated if a resident was receiving dialysis services, the MDS assessment should have reflected it. She stated she knew Resident #97 but did not know if Resident #97 received dialysis services. She stated she had not completed a MDS assessment for Resident #97. She stated she was not aware that Resident #97's MDS assessment did not reflect resident received dialysis. She stated if a MDS assessment was completed it could have affected the triggers on the resident matrix, but she did not feel like it could have necessarily affected residents. A record review of the facility's Minimum Data Set (MDS) Nursing Policies and Procedures, dated 2023, complete revision: 5/5/2023, email revision: 09/28/2023 reflected Policy: A licensed nurse will conduct or coordinate each assessment with the interdisciplinary team. An MDS, which is a comprehensive, accurate, standardized reproducible assessment will be completed for each resident, using the RAI process. Facility staff complete a comprehensive assessment of each resident's needs, strengths, goals, life history, and preferences, and offer guidance for further assessment once problems have been identified. The comprehensive assessment is completed initially and periodically.Procedures: 1. Review the resident's medical record. This review may include pre-admission activities. Identify resident's status, care and services rendered during the Observation Period for the current assessment. Review is to include but not be limited to pre-admission, admission, and transfer notes; current plan of care, physicians' orders, progress notes, history and physical; nursing, dietary, activity, social service, and therapy notes and assessments; monthly summaries, lab and x-ray reports, consultations, medication administration records, treatment administration records, and resident, staff and family interviews .

FACILITY Environment 46708 Based on observations, interviews, and record review, the facility failed to accommodate the needs and preferences for four (Resident #50, Resident #56, Resident #57 and Resident 66) of 10 residents reviewed for accommodation of needs, in that: The facility failed to ensure Resident #56, Resident #57, and Resident #66 had their call lights within reach. This deficient practice could place residents at risk for falls, not receiving care and nursing interventions in a timely manner, and subject them to skin breakdown. Findings included: Review of Resident #56's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including dementia, cognitive communication deficit, symbolic dysfunctions (a language disorder), abnormalities of gait and mobility, and need for assistance with personal care. Review of Resident #56's MDS, dated [DATE], reflected a BIMS score of 00, indicating severe cognitive impairment. It further reflected she utilized a wheelchair and required extensive assistance with eating, transferring, bed mobility, and toileting. Review of Resident #56's care plan start date10/03/2022, reflected she was a fall risk and to keep call light in reach at all times. Review of Resident #57's undated face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including senile degeneration of brain, zoster (a viral infection that causes an outbreak of a painful rash or blisters on the skin), bipolar disorder, acute upper respiratory infection, symptoms and signs involving the circulatory and respiratory systems, nonsurgical wound dressing-monitor wound, pain, unspecified, restlessness and agitation, anxiety disorder due to known physiological condition, dementia, Parkinson's disease, Alzheimer's disease, chronic pain due to trauma, and essential hypertension. Review of Resident #57's MDS, dated [DATE], reflected a BIMS score of 06, indicating severe cognitive impairment. It further reflected she utilized a wheelchair and was dependent with toileting and transfers. Review of Resident #57's care plan start date 08/07/2023, reflected she was a fall risk and to keep call light in reach at all times. Review of Resident #66's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] last admission 05/28/2024 with diagnoses including unsteadiness on feet, Type 2 diabetes, hyperosmolality (the blood has a high concentration of salt (sodium), glucose, and other substances) and hypernatremia (high sodium concentration, muscle weakness, need for assistance with personal care, abnormalities of gait and mobility, cognitive communication deficit, dehydration, Alzheimer's disease, and chronic obstructive pulmonary disease. Review of Resident #66's MDS, dated [DATE], reflected a BIMS score of 03, indicating severe cognitive impairment. It further reflected she utilized a wheelchair and required extensive assistance with bed mobility and transferring and total dependence with toileting. Review of Resident #66's care plan start date12/14/2023, reflected she was a fall risk and to keep call light in reach at all times. Observation on 06/11/2023 at 10:35 am revealed Resident #56's call light was not in reach. Surveyor attempted to interview Resident #56, but she was not interviewable. Observation on 06/11/2024 at 1:25 pm revealed Resident #57's door open and heard Resident #57 calling out, help me several times. Observation on 06/11/2024 at 1:30 pm revealed Resident #57's call light located between the wall and the back of her bed side table, out of Resident #57's reach. When surveyor entered the room Resident #57 said, I feel so stupid. Surveyor attempted to interview Resident #57, but she was not interviewable. Observation on 06/11/2024 at 1:35 pm revealed CNA C entered Resident #57's room. When CNA C exited Resident #57's room, surveyor entered the room and observed Resident #57's call light located between the wall and the back of her bedside table, out of Resident #57's reach. Observation on 06/12/2024 at 9:05 am of Resident #66's call light revealed it was in the trashcan located next to Resident #66's bed, out of Resident #66's reach. Review of facility policy titled Facility Call Lights, Responding To dated 05/05/2023 reflected: Policy - The staff will respond to call lights or other requests for assistance to meet the patient's/resident's needs. When leaving the patient or resident room, ensure the call light is placed within the patient's/resident's reach.

Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Residents #1) reviewed for adequate supervision. The facility failed to provide Resident #1 with adequate supervision and monitoring related to his wandering behaviors which resulted in an elopement to an apartment complex by EMS. Resident #1 was absent from the facility for approximately 7 hours before he was noticed by staff that he was missing. This failure could affect residents who and place them at risk for physical harm and or pain. An Immediate Jeopardy (IJ) was identified on 3/28/2024. The IJ template was provided to the Administrator and DON on 3/28/2024 at 5:12 PM While the IJ was removed on 3/29/2024 at 1:45 PM, the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need evaluate the effectiveness of the corrective systems. These failures could place residents at risk for possible serious injuries, harm and death to residents who require supervision. Findings include: Record review of Resident #1's face sheet, dated 3/27/2024, revealed a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Dementia (loss of cognitive functioning - thinking, remembering, and reasoning), abnormalities of gait and mobility, cognitive communication deficit. Record review of Resident #1's H/P dated 3/31/2023 revealed the following in part: .He (Resident #1) ran away from the home .and family member is afraid that he (Resident #1) will escape. Record review of Resident #1's care plan dated 10/4/2023 revealed the following in part: Problem - Exhibits risk factors for elopement risk. Goal - will not have any episodes of elopement over the next 90 days. Approach - 1. Assess resident for increased confusion, s/s of possible elopement as needed. 2. Convey an attitude of acceptance toward the resident. 3. Document about situation and complete elopement risk assessment with any increase in s/s of possible elopement risk, report such episodes to physician as needed. Record review of Resident #1's care plan dated 3/21/2024 revealed the following in part: Problem start date: 3/21/2024 - Resident #1 experienced an elopement r/t Dementia and confusion. Long Term Goal Target Date 6/21/2024 -Resident will not have any unaddressed episodes of elopement over the next 90 days. Approach: 1. Assess resident for increased confusion, s/s of possible elopement as needed. 2. Document about situation and complete elopement risk assessment with any increase in s/s of possible elopement risk, report such episodes to the physician as needed. 3. Elopement assessment completed. 4. Medication review. 5. Social service to review, refer out to secure unit as necessary. Problem - Exhibits risk factors for elopement risk. Goal - will not have any episodes of elopement over the next 90 days. Approach - 1. Assess resident for increased confusion, s/s of possible elopement as needed. 2. Convey an attitude of acceptance toward the resident. 3. Document about situation and complete elopement risk assessment with any increase in s/s of possible elopement risk, report such episodes to physician as needed. Record review of Resident #1's quarterly MDS, dated [DATE], revealed Resident #1 had a BIMS of 06, which indicated severe cognitive impairment. Section GG 120 - indicated Resident #1 used a walker (not accurate it was a cane). Section GG 170 - Mobility - Resident #1 is independent to walk 150 feet once standing the ability to walk at least 150 feet in a corridor or similar space. Wandering was not indicated for the lookback period for this MDS. Record review of Resident #1's progress notes dated 6/30/2023 - 3/20/2024 revealed the following: Elopement - 3/20/24 - found at hospital emergency room . Exit seeking - 1/29/24, 1/23/24,10/3/23, 6/30/23. Wandering - 1/28/24, 2/13/24, 3/5/24, 8/20/23 Record review of Resident #1's admission Elopement assessment dated [DATE] revealed the following in part: Is the patient confused? Answer: Yes Does the patient/resident have a history of wandering? Answer: Yes Is the patient/resident ambulatory/propels self? Answer: Yes Does the patient/resident have a diagnosis that requires supervision? Answer: Yes Decision: Proceed or Do not proceed. There is no answer or intervention documented. Record review of Resident #1's progress note, dated 3/20/2024 at 7:10 PM (late entry 3/22/2024 at 4:14 AM) by RN A revealed the following in part . Resident observed not to be in facility he was located on a neighboring property (nearby local hospita) by staff and returned to facility . Record review of Resident 1's progress note, dated 3/20/2024 at 10:30 PM (late entry 3/22/2024 at 2:49 AM) by RN B revealed the following in part . On arrival to facility, patient (Resident #1) was not able to be located by staff, whom reported the concern .Nurse supervisor (RN B) made contact with ER staff at name hospital, patient was confirmed to haven admitted .returned to facility at approximately 9:30 PM . Record review of EMS run sheet dated 3/20/24 revealed Resident #1 was seen at 2:44 PM at an apartment complex (.4 miles away from facility) and transported to a nearby hospital. Resident #1 was transferred to the hospital's care at 2:59 PM. Record review of Resident #1's MAR dated 3/20/2024 revealed the following: Resident #1 was not administered Donepezil 10mg tablet (prescribed for dementia) at 7:00 PM on 3/20/2024. Reason: Not administered - Resident Unavailable. Resident #1 was not administered Namenda 10mg tablet (prescribed for dementia) 7:00 PM on 3/20/2024. Reason: Not administered - Resident Unavailable. Interview on 3/27/2024 at 1:25 PM with DON, said she was notified approximately at 9:05 PM on 3/20/2027 when Resident #1 was not able to be located by RN B. The DON said staff should make rounds at least every 2 hours to ensure residents are present and if care is needed. The DON said all staff are responsible and should ensure residents are supervised and monitored. The DON said there is not a specific training or protocol that staff are trained on to confirm residents are present in the facility. Interview on 3/27/2024 at 2:15 PM ADON A said she worked on the day Resident #1 eloped from the facility. ADON A said she worked from approximately 9:00 AM to 9:00 PM. ADON A said she was normally in the office working and did not recall seeing Resident #1. She said Resident #1 wandered around the building daily. ADON A said the facility addressed his wandering by generally redirecting him (Resident #1). She said she was not able to give an exact time for when to round, but it should have been done every 1-2 hours. ADON A said staff should be mindful of Resident #1 because he wandered, which made him an elopement risk. ADON A said she was informed Resident #1 was missing when RN B arrived for his shift at approximately 7:45 PM. ADON A said she called Resident #'s family member to see if he was out on pass. ADON A said she received training on the elopement protocol, but there was no specific guidance regarding the frequency of resident being monitored during a shift. She said there was not a specific protocol on how staff members are monitored to ensure residents receive adequate supervision every two hours. ADON A said staff who worked directly with Resident #1 should have ensured he was present during their shift and if he was not seen, a Charge Nurse or ADON should have been notified. Interview on 3/27/2024 at 3:04 PM, RN B said he arrived at work at approximately 8:00 PM. He said he was told immediately by RN A that Resident #1 was missing. He said after they searched, he went to a nearby hospital to see if Resident #1 was there. He said he found the resident in the ER and brought him back, by car to the facility at approximately 9:05 PM. He said Resident #1 was not able to verbalize where he had been. He said Resident #1 had wandered out to the parking lot and was brought back in with no incident . He said it was not documented because the resident was easily redirected. He said Resident #1 would stand by exit doors. He said there was not an intervention to prevent Resident #1 from standing at the doors, but he would redirect Resident #1 when he wandered. Interview on 3/27/2024 at 3:23 PM, CNA A said she was assigned to Resident #1 for the 2:00 PM - 10:00 PM shift on the day Resident #1 eloped. CNA A said she did not see Resident #1 at the beginning of her shift and assumed he was in another part of the building with family member. She said he normally wandered around the building. She said she was told by nursing staff to redirect Resident #1 if she saw him wandering. She said she was not aware of his care-plan interventions related to elopement risk. CNA A said she was not able to do shift change with CNA B due to her being late to work. CNA A said approximately at 4:30 PM, when she was passing meal trays, she asked at the nurse's station if anyone had seen Resident #1. She said she did not receive an answer and could not remember the staff that were around the nurse station. She said she did not alert staff at that time that she had not seen Resident #1. She said she continued with her work duties. She said between 7:30 PM and 8:00 PM she picked up the meal trays and saw that Resident #1's tray was in his room untouched. CNA A said CNA C said she had not seen Resident #1 during the shift either. CNA A said she looked with RN A in another area of the building and did not find him. She said she should have ensured the resident was present in the building when she was not able to locate him throughout her shift. She said she is supposed to round every 2 hours but during her rounds she did not see Resident #1. Interview on 3/27/2024 at 3:58 PM, CNA C said she worked the 2:00 PM - 10:00 PM shift when Resident #1 eloped. She said she was not assigned to Resident #1 and had not seen him during her shift. She said she was supposed to round every two hours for the residents she was assigned. She said she does not document if a resident was present, she would visually verify a resident is present. She said after dinner, approximately 6:30 PM, she was asked by CNA A if she had seen Resident #1 and she told her she had not. CNA C said she looked for Resident #1 with CNA A after dinner in other areas of the building and did not see him. She said she returned to her duties for her assigned residents for the rest of the shift. Interview on 3/27/2024 at 4:16 PM, RN A said she worked the 6:00 PM to 6:00 AM shift when Resident #1 eloped. She said arrived approximately 6:15 PM. She said she started medication administration and Resident #1 was not in his room and she remember his dinner tray in the rooms. She said she saw his cane as well and assumed Resident #1 was in the bathroom. She said she did not check the bathroom or verify if Resident #1 was present. She said she continued with the medication pass. She said she was alerted by CNA A that Resident #1 was not able to be located. She said all staff looked for the resident for maybe 30 minutes. She said she informed RN B that Resident #1 was not able to be located. She said she notified RN B at the start of his shift, approximately at 7:45 PM, that Resident #1 could not be located. RN A said we monitored residents by rounding and checking on them. RN A said we don't have a check off to document a resident is in the building, but she said there was a sign out sheet for residents out on pass. She said she did not check that sheet. She said residents with elopement risk do not have a specific monitoring schedule. Interview on 3/28/2024 at 11:20 AM, LVN A said had worked with Resident #1 before but not on the day he eloped. LVN A said Resident #1 would wander around the building, go into resident rooms, and go towards the exit doors at the end of the hallways. She said she would redirect Resident #1 when he was at the exit doors. She said there was not a protocol related to accounting for a resident visually or if a resident was in the building. She said they round every 2 hours but did not explain what is done if the resident is not seen every 2 hours. She said she thought one of Resident #1's interventions were frequent monitoring but was not sure. Interview on 3/28/2024 at 12:20 PM, ADON B said it was common knowledge that a CNA would have learned in there CNA training to round every 2 hours and visually see residents to ensure they are supervised or monitored. ADON B said Resident #1 wandered the building and staff were instructed to redirect him. She said residents should be monitored to make sure they are in their rooms or the building but there was no specific documentation related to that. ADON B said she was not able explain why staff would not question where Resident #1 was during an 8-hour shift. Interview on 3/28/2024 at 2:20 PM, CNA B said she worked that 6:00 AM - 2:00 PM shift when Resident #1 eloped. She said she assisted Resident #1 up that morning and helped him to breakfast. She said it was normal for Resident #1 to wander around the building constantly. She said she had been trained to redirect Resident #1 when he wandered. She said she saw the resident eat lunch with his spouse approximately 11:30 AM - 12:00 PM. CNA B said she last saw Resident #1 approximately 1:45 PM, near the nurses' station watching TV on the skilled hall before she went to lunch. She said she did not return to that side of the building because she went to work on the long-term side for another shift. She said previously Resident #1 would attempt to the exit the long-term care exit doors when visitor would enter or exit the building. CNA B said she was instructed to redirect him. She said the DON, ADON or Charge Nurse were responsible and ensured CNAs supervised and monitored residents. Interview on 3/28/2024 at 3:22 PM, Administrator said the staff supervised and monitored residents by rounding. He said an example would be when staff completed medication administration. Administrator said Resident #1 would be monitored throughout the halls as he wandered. He said there was no specific training or policy to ensure resident was present in the building throughout the shift. He said he expected staff to round every 2 hours to monitor resident. He said he was informed approximately after 8:00 PM that Resident #1 was unable to be located. Administrator said he interviewed the staff that worked 2:00 PM - 10:00 PM. He said they reported on the day Resident #1 eloped and they did not find it weird or report the resident was missing because he wandered a lot and they thought he may have been with his on pass. Administrator said there was no sign in and out sheet for residents on pass . He said he did not know how staff tracked residents out on pass. Administrator said the CNA's and Nurses were responsible for ensuring residents were supervised during the shift. Administrator said it was the CNA's and Nurses responsibility to ensure the residents are present in the building and they should have rounded to monitor residents location. Interview on 3/28/2023 at 4:03 PM, ADON B said she was not sure who was responsible and reviewed the sign-in and out sheet for residents out on pass. She said she was not sure if staff reviewed the sign in and out sheet to verify if Resident #1 was out on pass. Observation on 3/28/2024 at 5:20 PM revealed, the main street to the facility had moderate traffic with fast moving vehicles. The main street had 3 unhoused citizens asking for money. The main street (four lanes) to the facility had posted speed limits of 35 mile per hour. The apartment complex that Resident #1 was seen at by EMS was .4 miles away from the facility. Record review of facility out of facility/on pass Sign in and out Sheet for residents dated March 2024 revealed two names on the form and it did not have Resident #1 on it. In an interview 3/28/2024 at 3:22PM, Administrator said the facility did not have a policy on supervision or how residents were monitored by staff throughout a shift . Record review of facility job description for Certified Nursing Assistant dated 6/27/2008 (Rev. 11/2016) revealed the following in part: To provide routine daily nursing care and services that support the care delivered to patients/residents residing in the facility in accordance with the established nursing care policy and procedures as directed by the supervisor . 3. Safety concerns are identified, and appropriate actions are taken to assure a patient [sic] safety. 4. Reports to the nursing supervisor any observations and pertinent information related to the care of the patient/resident. 20. Communication A. Reports all changes in a patients/residents condition as soon as possible to the nursing supervisor (LPN/LVN/RN) Standard Responsibilities: 5. C. Compliance with all regulatory requirements. Record review of facility job description for Registered Nurse dated 5/2/2005 (Rev. 11/2016) revealed the following in part: To plan and deliver nursing care to patients/residents requiring long-term and/or rehabilitative care. 1. Works using the guidelines established by the Nurse Practice Act, facility Policies and Procedures, and sound nursing judgement. 17. General Patient/Resident Care B. Interventions are performed in a timely manner. Explanations for delays in answers/responses are provided. E. Safety concerns are identified, and appropriate actions are taken to maintain and assure patient safety . Record review of facility Elopement policy dated (Complete revision 11/1/2017) revealed the following in part: To safely and timely redirect patient/residents to a safe environment. A prompt investigation and search will be conducted if a patient/resident is considered missing. The facility will determine a signal code, e.g. Code [NAME] to designate a missing patient/resident. This was determined to be an Immediate Jeopardy (IJ) on 3/28/2024. The Administrator and DON were notified. The Administrator was provide with the IJ template on 3/28/2024 at 5:12 PM. A plan of removal was requested. The following Plan of Removal was submitted by the facility and was accepted on 3/29/2024 at 9:14 AM. Date:3/28/24 F689 The facility failed to provide adequate supervision for Resident #1. Immediate action: Identified resident no longer resides at facility. Resident discharged home with on 3/25/24. 1:1 education provided to CNA A. CNA B, and RN A by the Director of Nursing on 3/29/24 on resident care and the elopement policy which included checking for residents needs approximately every 2 hours, validating during shift change resident's location, and notifying their supervisor immediately if a resident is not accounted for additional direction. Elopement assessments completed in the past 90 days on current residents in the facility will be reviewed by nursing managers for accuracy on 3/28/24. Any not completed in past 90 days or found to be inaccurate will be completed by the Director of Nursing on 3/28/24. None were identified as inaccurate. Identified residents at risk will be reviewed using the Elopement Risk Assessment for interventions on 3/28/24, by the Director of Nursing and any issues identified were corrected at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 3/28/24. 10 residents identified as an elopement risk had their care plan updated. Facility Doors were validated to be in proper working order by Maintenance Director on 3/28/24. Facilities Plan to ensure compliance quickly Licensed Nurses will be reeducated on Accidents and Incidents, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified, which may include every 6 hour documentation to validate the resident's location. Nursing Staff will be reeducated on resident care and the elopement policy that includes o Checking for residents needs approximately every 2 hours o Validating during shift change resident's location o Notifications to Charge Nurse or Director of Nursing as indicated when a resident is not located This reeducation will be completed by the Director of Nursing/Designee on 3/28/24. Any member of the target audience not receiving this reeducation by 3/28/24 will receive prior to their next scheduled shift. This will be presented in New Hire Orientation. An elopement drill will be completed on 3/29/24 that includes: o The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill Procedure o The Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutes o If the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying information o The Search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radius o When the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress. The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative. o The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences o When the missing resident is found, an announcement will be made, Code [NAME] all clear. The Medical Director was notified of the Immediate Jeopardy on 3/28/24 Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 3/28/24 to discuss contents of this plan. Monitoring of the POR included: Identified resident no longer resides at facility. Resident discharged home with spouse on 3/25/24. 1:1 education provided to CNA A. CNA B, and RN A by the DON on 3/29/24 on resident care and the elopement policy which included checking for residents needs approximately every 2 hours, validating during shift change resident's location, and notifying their supervisor immediately if a resident is not accounted for additional direction. Elopement assessments completed in the past 90 days on current residents in the facility will be reviewed by nursing managers for accuracy on 3/28/24. Any not completed in past 90 days or found to be inaccurate will be completed by the DON on 3/28/24. None were identified as inaccurate. Identified residents at risk will be reviewed using the Elopement Risk Assessment for interventions on 3/28/24, by the Director of Nursing and any issues identified were corrected at the time of discovery. Care plans were updated to reflect the interventions by the Nurse Assessment Coordinator on 3/28/24. 10 residents identified as an elopement risk had their care plan updated. Facility Doors were validated to be in proper working order by Maintenance Director on 3/28/24. Facilities Plan to ensure compliance quickly Licensed Nurses will be reeducated on Accidents and Incidents, the elopement risk assessment process/accuracy and putting interventions in place based on the risks identified, which may include every 6-hour documentation to validate the resident's location. Nursing Staff will be reeducated on resident care and the elopement policy that includes. o Checking for residents needs approximately every 2 hours. o Validating during shift change resident's location. o Notifications to Charge Nurse or Director of Nursing as indicated when a resident is not located. This reeducation will be completed by the Director of Nursing/Designee on 3/28/24. Any member of the target audience not receiving this reeducation by 3/28/24 will receive prior to their next scheduled shift. This will be presented in New Hire Orientation. An elopement drill will be completed on 3/29/24 that includes: o The Administrator will notify the Charge Nurse, Director of Nursing and Social Service Designee that a resident is missing. The Director of Nursing/designee will announce Code [NAME] to signal the Elopement Drill Procedure o The Director of Nursing/designee will organize an immediate and thorough search of the center and surrounding grounds. The entire search process will be completed within 30 minutes o If the search fails to locate the missing resident in the allotted time, the Administrator/designee will place a mock telephone call to the appropriate community agencies, resident's legal representative and attending physician. Staff will provide the mock police with all the physical identifying information. o The search will continue if resident not located to include 2 staff members searching the surrounding streets by care for a 2 mile radius o When the volunteer resident is located the Charge Nurse will complete a head to toe assessment. The Social Services Designee will assess the resident for emotional distress. The Director of Nursing will notify the appropriate community agencies, attending physician and the resident's legal representative. o The facility's Quality Assurance Committee will investigate the incident and implement interventions to prevent reoccurrences. o When the missing resident is found, an announcement will be made, Code [NAME] all clear. The Medical Director was notified of the Immediate Jeopardy on 3/28/24. Ad Hoc Quality Assurance and Performance Improvement Meeting was held on 3/28/24 to discuss contents of this plan. 9:30am-Record review of the listed residents Elopement risk seemed to be current and accurate. 10:15am-Record review of Inservice Title: Resident Monitoring/Incident/Accidents/Elopement. The Inservice was developed by DON on 03/27/24. o Round q 2 hours during general rounds, attention to those at risk for wandering/elopement. o Charge nurse does q 6-hour location verification in the record. o Check for location of at-risk residents during change of shift rounds. o Notify Charge Nurse/ADON or DON if resident is not located during this process o Nurse performs Elopement assessment, if identified as an elopement risk, the resident profile is updated, the MDS team will care plan with interventions. ADON/DON is notified. o NOTIFY DON/ADMINISTRATOR IMMEDIATELY IF A RESIDENT IS NOT LOCATED ON INITIAL SEARCH. 10:47am-The following staff were interviewed regarding In-Service Resident Monitoring/Incident/Accidents/Elopement. Staff were able to answer questions in a satisfactory manner and did not raise any concerns. 10:50am-Interview conducted with LVN D. 10:55am-Interview conducted with Restorative aide A. 11:00am Interview conducted with CNA D. 11:06am-Interview conducted with LVN B. 11:11am-interview conducted with ADON A. 11:15am-Interview conducted with LVN C. 11:20am-Interview conducted with CNA E. 11:24am-Interview conducted with Med Aide A. 11:30am-Interview conducted with CNA F. 11:36am-Interview conducted with CNA G. 11:45am-Interview conducted with LVN D. 11:50am-Interview conducted with CNA H. 12:00pm-Observations of staff and resident's interactions during lunch and on hallways did not raise any concerns and residents were being appropriately supervised. Residents were dressed appropriately none of the residents appeared to be in distress. Also while rounding observations were made of exit doors and all doors appeared to be secure and were fitted with an alarm in case of anyone exiting the door. 12:30pm-Record review of facility documentation from Maintenance Director dated 03/28/24 indicated that all exit doors were checked on 03/27/24 and were in working order. 1:00pm-Record review of document tilted Elopement Drill indicated that an Elopement Drill was conducted on 3/28/24 with 16 staff and RN B conducted the drill. 1:10pm-Attempted to call RN B for interview but was unable to reach him. 1:15pm-Interview with DON revealed that she wrote the Inservice and that she in-serviced staff on Service Resident Monitoring/Incident/Accidents/Elopement.] An Immediate Jeopardy (IJ) was identified on 3/28/2024. The IJ template was provided to the Administrator and DON on 3/28/2024 at 5:12 PM While the IJ was removed on 3/29/2024 , the facility remained out of compliance at a severity of no actual harm with potential for more than minimal harm that is not an immediate jeopardy and a scope of isolated, due to the facility's need evaluate the effectiveness of the corrective systems.

Based on observation, interview and record review, the facility failed to ensure residents were free from neglect for 3 of 11 (CR #1, Resident #1, and Resident #2) were reviewed for neglect. -The facility failed to have an effective wound management and prevention program in place to ensure CR #1, Resident #1, and Resident #2 did not develop new or worsening PUs when they opened the quarantine and COVID halls. -The facility failed to have a process in place to effectively monitor and assess wounds when they opened the quarantine and COVID halls resulting in CR #1 developing a St IV right hip PU, a worsening St IV sacral PU [MEDICAL CONDITION], worsening of Resident #1's St IV sacral PU and development of osteo[DIAGNOSES REDACTED], and development of a FA St IV sacral PU and osteo[DIAGNOSES REDACTED] on Resident #2. -The facility failed to ensure all nursing staff were properly trained of had the compentencies to complete wound care when the Wound nurse was pulled to work the floor leaving multiple floor nurses to complete wound care. These failures resulted in an immediate jeopardy on 10/15/20. While the IJ was removed on 10/18/20 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures placed residents at risk of further neglect, pain, decline in health and/or hospitalization . Findings include; CR #1 Record review of CR #1's face sheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Care plan edited 10/02/20 read in part, Problem: Problem Start Date: 05/04/20 CR #1 has a pressure ulcer Stage IV to Sacrum .Goal: Resident's ulcer will not increase in size; Approach: Assess the pressure ulcer for location, stage, size, presence /absence of granulation tissue and epithelization . Record review of CR #1's Care Plan problem start edited 10/02/20 read in part, Problem Problem Start Date: 09/16/2020 CR #1 has a pressure ulcer STAGE IV TO R HIP; Goal: Resident's ulcer will heal without complications; Approach: .Assess the pressure ulcer for location, stage, and size, presence/absence of granulation tissue and epithelization .Conduct a systematic skin inspection. Report any signs of further skin breakdown . Record review of the facility's Weekly Wound Tracking Worksheet week of 6/08/20 revealed, CR #1's unstageable sacral PU measuring 3cm x 1.5cm x 1cm present on admission date of [DATE]. Record review of CR #1's physician orders [REDACTED].once a day; 06:00am-10:00pm. Record review of CR #1's June 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate, Cover with Dry Dressing. On 6/17/20 and 6/24/20 there was no documentation indicating wound care was completed. Record review of CR #1's Wound MD assessment notes dated 6/22/20 revealed, a FA unstageable right hip pressure ulcer measuring 2cm x 1cm. Date acquired documented as 6/21/20. Record review of the facility's Weekly Wound Tracking Worksheet week of 6/29/20 revealed, CR #1's St IV facility acquired right hip pressure ulcer measuring 0.2cm x 0.2cm x 0.1cm, with an onset date of 6/21/20. Further record review of the 6/29/20 Weekly report revealed, an unstageable sacral PU present on admission measuring 3cm x 1.5cm x 1cm. Record review of CR #1's physician orders [REDACTED].#1's FA St IV right hip PU. Record review of CR #1's June, July and August 2020 TAR revealed, no treatment orders and/or documentation indicating wound care was completed on his right hip PU. Record review of CR #1's Weekly Wound Tracking Worksheets revealed, two weekly reports for the weeks of 6/08/20 and 6/29/20. The Interim DON could not provide weekly worksheets for the months of May through August 2020 to review. Interview on 10/07/20 at 12:05pm with the Interim DON, she stated the Weekly Wound Tracking worksheets were not completed for the month of August because the Wound nurse was pulled to work on the COVID unit. She said she had the Wound MDs notes for August available for review. When asked if the weekly report was completed in July, she stated yes. Investigator requested the weekly reports for months of May, June and July. Interview on 10/07/20 at 12:39pm with the Interim DON, she stated they looked for the reports further stating they do not have weekly wound reports for the months of May, June, July, and August. She again stated that was the time the wound nurse was pulled to the COVID hall. She said she did locate two weekly reports completed in June. Interview on 10/07/20 at 12:46pm with the Wound Nurse, he said he started working the COVID unit when COVID started around March or April and began working as the wound nurse again the beginning of September end of August. When asked who completed wound care on the non-COVID halls, he stated the floor nurses, but stated he was not sure which nurses did the wound care. When asked how often wound care is completed, he stated wound care is done daily, further stating the floor nurses would have done it daily. Further interview on 10/07/20 at 12:46pm with the Wound Nurse, when asked where wound care is documented once completed, he stated on the TAR. When asked what is documented, he stated the pain score, drainage, color of the wound. He said if they did wound measurements it would be documented on the Wound Management Report. He said wound size, dimensions, and measurements were documented on the Wound Management report. When asked if wound care was documented in the nursing progress notes, he stated occasionally it's documented in the progress notes but mainly it was documented the on wound management report further stating the policy was to document on the wound management report. Record review of CR #1's Wound Management Detail Report dated 6/29/20 revealed, a St III FA right hip PU measuring 0.2cm x 0.2cm x 0.1cm (length x width x depth) with light serous (clear, amber, thin and watery) exudate with 100% granulation tissue. Further record review of the Wound Management Detail Report revealed, documentation indicating the wound resolved on 7/06/20. There were no Wound Management Detail reports for the months of July and August for CR #1's right hip wound. Record review of CR #1's July 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral with NS/WC Pat Dry Apply Calcium Alginate and Cover with Dry Dressing. On 7/4/20, 7/5/20, 7/9/20, 7/12/20, 7/23/20, 7/28/20, 7/29/20, 7/30/20, and 7/31/20 there was no documentation indicating wound care was completed. Record review of CR #1's Wound MD assessment notes dated 7/6/20 revealed, documentation the right hip PU resolved. On 7/12/20, CR #1's Weekly Skin Assessment revealed, documentation of a right hip PU measuring 2cm x 2cm. Record review of CR #1's nursing progress notes dated 7/12/2020 read in part, resident observed with new stage 1 pressure ulcer to right hip. Wound care done, family notified. Record review of CR #1's Weekly Skin assessment dated [DATE], 7/20/20 revealed there was no documentation of the right hip PU. Further record review of CR #1's Wound MD assessment notes dated 7/13/20 revealed, a present on admission St IV sacral PU measuring 3cm x 1cm x 1cm. There was no documentation of a right hip PU. Further record review of CR #1's Wound MD assessment notes revealed, no wound assessments completed for the last two weeks of July. The next wound assessment completed was on 8/03/20. Telephone interview on 10/14/20 at 11:33am with the Wound MD, when asked if he knew if wound care was being completed on residents during the time the quarantine and COVID halls opened, he stated he wasn't sure. He further stated he stayed away from the COVID unit. He said he was out for a two-week period in July because he tested positive. When asked if the facility communicated with him about any concerns or issues with wounds while he was out, he stated no, he had no communication with the facility during that time he was out and again could not state if wound care was being done. Record review of CR #1's dietary progress notes dated 7/23/20 read in part, RD Nut'l Monitoring note/TF/Wound-New: Per latest note new wound R hip (4 wounds) Wt: 126#/BMI: 20.69. Receiving: Decubivite and ACC protein (supplements) . Further record review of CR #1's Weekly Skin Assessments revealed, no skin assessment completed for the week of 7/27/20. Record review of the facility's August Wound Summary Report revealed, CR #1's FA St IV right hip pressure ulcer was not documented on the report. The Interim DON could not provide a Weekly Wound Tracking Worksheet for the month of August. Record review of CR #1's August 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate, Cover with Dry Dressing. On 8/1/20, 8/2/20, 8/4/20, 8/5/20, 8/6/20, 8/13/20, 8/15/20, 8/16/20, 8/24/20, 8/29/20, and 8/30/20 there was no documentation indicating wound care was completed. Record review of CR #1's Weekly Skin Assessments dated 8/03/20, 8/10/20, 8/17/20 revealed there was no documentation of the right hip PU. Further record review of CR #1's Weekly Skin Assessments revealed no weekly skin assessments completed for weeks of 8/24/20 and 8/31/20. Further interview on 10/07/20 at 12:46pm with the Wound Nurse, when asked who was responsible for completing the Weekly skin assessments, he stated he completed all PU related assessments and if the wound is not PU related, the nurses on the floor were responsible for completing the weekly skin assessment, further stating all residents have weekly skin assessments completed. He said the nurses should have been doing the weekly skin assessments when he was working on the COVID unit. He said because he was pulled to work on the quarantine and COVID units, the Weekly Wound Tracking Worksheets were not completed. Record review of CR #1's Wound MD assessment notes dated 8/03/20 revealed, a present on admission St IV sacral PU measuring 2.5cm x 2cm x 1.5cm. There was no documentation of a right hip PU. Further record review of CR #1's Wound MD assessment notes revealed no wound assessments completed on the St IV sacral wound on dates 8/10/20, 8/17/20, 8/24/20, 8/31/20, and 9/28/20. Record review of the Wound Management Detail Report dated 9/02/20, 9/7/20 and 9/14/20 revealed, a FA St IV right hip PU measuring 4cm x 4cm with moderate serous (clear, amber, thin and watery) exudate with 100% slough. Onset date documented as 9/02/20. Record review of CR #1's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? yes was documented. Further record review of the Weekly Skin Assessment comments read in part, Pressure wounds to sacral . TX orders in place There was no documentation of the right hip PU. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/07/20 revealed, CR #1's St IV sacral pressure ulcer measuring 2.5cm x 1.5cm x 1.5cm. The right hip wound was not documented on this weekly wound report. Interview on 10/07/20 at 3:16pm with the Wound nurse, he stated the Wound Management Detail report was completed weekly, stating typically on Mondays. He stated he entered what was on the MDs assessment notes onto this report. When asked during the time he worked on the quarantine and COVID halls, how did he complete the reports for those months when he was not assessing the residents, he stated he inputted the information from the MD notes, stating they were not his wound measurements or descriptions. He stated he does the initial wound measurements on admissions, then uses the Wound MD's measurements after that which are then documented on the Wound Management report. Interview on 10/07/20 at 3:16pm with the Wound Nurse, the investigator showed the Wound nurse the Weekly Wound Tracking Report for CR #1's right hip St IV PU which showed an onset date of 8/10/20, but the right hip wound was not documented on the 9/7/20 report, he stated it was a documentation error and should have been documented on the 9/7/20 report. Record review of CR #1's dietary progress notes dated 9/10/20 read in part, RD Nut'l Monitoring Note/TF/Wound-New: Per latest note new wound R hip (4 wounds) Wt: 128#/BMI:20.69, 2# rebound. Receiving decubivite and protein. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/15/20 revealed, CR'#1 FA St IV right hip pressure ulcer measuring 4cm x 4cm with an onset date of 8/10/20 and a St IV sacral pressure ulcer measuring 3cm x 2.5cm x 1.5cm. Record review of CR #1's Wound Management Detail Report dated 9/21/20 revealed, a St IV FA right hip PU measuring 3cm x 5cm x 1.5cm, with moderate serous (clear, amber, thin and watery) exudate, and 100% slough. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/28/20 revealed, CR #1's St IV right hip facility acquired pressure ulcer measuring 5cm x 6cm x 3cm with an onset date of 8/10/20 and a St IV sacral pressure ulcer measuring 4cm x 3cm x 2.5cm. Record review of the CR #1's Wound Management Detail Report dated 9/28/20 revealed, documentation of a St IV right hip pressure ulcer measuring 5cm x 6cm x 3cm, moderate purulent (opaque, milky; sometimes green) exudate, with necrotic tissue and 50% slough. It further revealed a St IV sacral PU measuring 4cm x 3cm x 2.5cm with moderate serosanguinous (pale, red to pink, thin and watery) exudate. Record review of CR #1's physician orders [REDACTED].Once a day. Further record review of the physician's orders [REDACTED].Once a day. Further record review of CR #1's September 2020 TAR revealed, on 9/20/20 there was no documentation indicating wound care was completed. Further record review of the September 2020 TAR revealed wound care was not ordered until 9/15/20 when the wound was identified on 9/02/20 on the Wound MD assessment notes and was documented as identieid on 8/10/20 on the Weekly Wound Tracking sheet dated 9/28/20. Further record review of CR #1's September 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate, Cover with Dry Dressing. On 9/5/20, 9/6/20, and 9/20/20 there was no documentation indicating wound care was completed. Further interview on 10/07/20 at 3:16pm with the Wound nurse, when asked if the floor nurses were completing daily wound care, and if changes in the wounds were identified, should the details of these changes be documented in the progress notes, weekly skin assessments/observations, and TAR, he said it should be on the observation notes. He stated the nurses should measure the wounds and if there were changes, document the changes on the reports or progress notes. When informed the TAR only requires use of codes to describe the wounds and does not have an area to document measurements, he said measurements should be documented if there are changes. When asked if the Weekly Wound Tracking sheet should be accurate and reflect the correct wound onset dates and wounds identified, he stated yes. Interview on 10/07/20 at 3:28 pm with the Interim DON, when the investigator showed the DON the TARs for the months of June through current date with the multiple blanks spots where wound care should have been documented, she said she can't explain what happened, stating they just completed skin sweeps on all residents. She said she can't explain what happened and why there was no documentation. When asked if she knew if wound care was completed, she could not state. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed he was discharged to an acute hospital on [DATE] with four St IV pressure ulcers, with 1 present on admission/re-admission. Record review of CR #1's hospital progress notes dated 10/01/20 revealed, the resident was admitted to the hospital with [REDACTED]. Record review of CR #1's Emergency Department Provider Documentation dated 10/01/20 read in part, .History obtained from previous records as none was given by EMS or transferring facility. He is hypotensive. Actively bleeding from right hip decubitus ulcer. All wounds evaluated, clean, and redressed by myself, with surgical packed to bleeding wound. Septic work-up ordered. Patient's (family member) here .she is unsure of when bleeding to right hip started, as she was not notified . Record review of CR #1's Radiology report dated 10/01/20 read in part, Impression: 1. Decubitus ulcer in the lower sacrum with adjacent cortical erosion of the S1 concerning for osteo[DIAGNOSES REDACTED] (an infection of the bone). 2. Decubitus ulcer on the lateral aspect of the right gluteal region with adjacent soft tissue [MEDICAL CONDITION]. There is adjacent cortical erosion of the S1 .concerning for osteo[DIAGNOSES REDACTED] . Resident #1 Record review of Resident #1's face sheet revealed, a [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1 Quarterly MDS dated [DATE] read in part, Section M .Risk of Pressure Ulcers/Injuries: Is this resident at risk of developing pressure ulcers/injuries? Yes was documented. Further record review of Resident #1's Quarterly MDS revealed, documentation of 1 Stage 2 PU present on admission, 2 stage 3 PUs present on admission, and 1 Stage IV PU present on admission. Record review of Resident #1's Admission assessment dated [DATE] revealed, Alterations in skin? No was documented. Further record review of the Admission Assessment comments read in part, Stage 3 sacral pu. Record review of Resident #1's Admission assessment dated [DATE] revealed, Alterations in skin? Yes documented. Further record review of the Admission Assessment read in part, Wound Location- sacrum; Length .3.5 (cm); Width .3 (cm) . Record review of Resident #1's Focused Observation dated 8/12/20 revealed, Alterations in skin? Yes was documented. Further record review of the Focused Observation read in part, Ulcer; Location: sacrum, Length: . 12(cm); Width: . 10.5 (cm) .Wound/Ulcer type: Pressure ulcer; Stage: Unstageable: Slough and/or Eschar; .Depth of tissue injury: Full thickness: Through dermis & down to subq tissue, muscle; Wound bed descriptions: Tissue Type and Color: Slough: yellow, green, gray, nonviable (necrotic) tissue, usually light in color, thin, wet stringy .Date Wound Identified: 07/28/2020 . Record review of the facility's Weekly Wound Tracking Worksheet week revealed no reports for the months of July and August 2020 to review for Resident #1. Record review of Resident #1's Focused Observation; Weekly skin dated 8/27/20 revealed, Alterations in skin? Yes was documented. Further record review of the Focused Observation; Weekly skin read in part, Wound Location-sacrum; Length .15 (cm); Width .10 (cm) . Record review of Resident #1's August 2020 TAR read in part, Daily Wound Treatment: Sacral. Cleanse wound with NC/WC Pat Dry Apply Santyl and Calcium Alginate, Cover with Dry Dressing Daily. Further record review of Resident #1's August 2020 TAR revealed, on 8/13/20, 8/14/20, 8/15/20, 8/16/20, 8/17/20, 8/24/20, 8/29/20, 8/30/20, and 8/31/20 there was no documentation indicating wound care was completed. Further record Review of Resident #1's Focused Observation; Weekly skin dated 9/3/20 and 9/07/20 revealed, Alterations in skin? Yes was documented. Further record review of the Focused Observation; Weekly skin comments revealed she had a sacral wound. Record review of Resident #1's Care plan edit date 10/12/20 read in part, Problem: Problem Start Date: 9/08/2020 Resident has a pressure ulcer STAGE IV TO SACRAL; Goal: Resident's ulcer will heal without complications; Approach: Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization WEEKLY. Conduct a systematic skin inspection WEEKLY. Report any signs of any further skin breakdown . There was no documentation of osteo[DIAGNOSES REDACTED] with PO antibiotics or IV antibiotic treatment for [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Further record review of Resident #1' physician orders [REDACTED]. Cleanse Wound with NS/WC Pat Dry Apply Silver Alginate Cover with Dry Dressing Daily. Once a Day 06:00AM-10:00PM Record review of Resident #1's September 2020 TAR revealed, on 9/5/20 and 9/6/20 there was no documentation indicating wound care was completed on her sacrum. Record review of Resident #1's Readmission Focused Observation dated 9/23/20 revealed, Alterations in skin? Yes was documented. Further record review of the Readmission Focused Observation comments read in part, Resident has pressure wound to sacral at 11 (cm) x 10 (cm) x 2.5 (cm), R buttocks at 3 (cm) x 1.5 (cm) . Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? Yes was documented. Further record review of the Weekly Skin assessment comments read in part, Resident has pressure ulcer wound to sacral, R buttocks . Record review of the facility's Weekly Wound Tracking Worksheet week of 9/7/20 revealed, a community acquired St IV sacral PU measuring 7cm x 10cm with an onset date of 7/28/20. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/28/20 revealed, a community acquired St IV sacral PU measuring 10cm x 11cm x 3cm with an onset date of 9/4/20. Interview on 10/07/20 at 3:16pm with the Wound Nurse, when the investigator showed the treatment nurse the Weekly Wound Tracking report for weeks of 9/28/20 for Resident #1s St IV Sacral PU which had an onset date of 9/4/20, then on the Weekly Wound Tracking report week of 9/7/20, the onset date was documented 7/28/20. He stated that was also a documentation error, further stating she was admitted with a sacral wound on 7/28/20, stating the onset date should be 7/28/20. Record review of Resident #1's Wound MD notes dated 9/28/20 revealed, documentation of a St IV present on admission sacral PU measuring 10cm x 11cm x 3cm with an onset date of 9/4/20. Further record review of the Wound MD assessment notes read in part, 25% necrotic bone currently on oral antibiotic for osteo[DIAGNOSES REDACTED] until 10/24/20. There was no documentation of the IV antibiotic ordered [MEDICAL CONDITION]. Further record review of Resident #1's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? Yes was documented. Further record review of the Weekly Skin assessment comments section read in part, Resident has pressure ulcer wound to sacral, R buttocks, L buttocks . Record review of the facility's Weekly Wound Tracking Worksheet week of 10/05/20 revealed Resident #1 had a community acquired St IV sacral PU measuring 11cm x 11cm x 3cm with an onset date of 9/4/20. Record review of Resident #1's Wound Management Detail Report dated 10/05/20 revealed, a St IV sacral PU present on Admission/Re-entry measuring 11cm x 11cm x 3cm with moderate serous (clear, amber, tin and watery) exudate with 25% slough and 75% granulation tissue. The date identified was documented 8/10/20. Record review of Resident #1's Wound MD notes dated 10/05/20 revealed, documentation of a St IV present on admission sacral PU measuring 11cm x 11cm x 3cm with an onset date of 9/4/20. Further record review of the Wound MD assessment notes read in part, currently on oral antibiotic for osteo[DIAGNOSES REDACTED] until 10/24/20. There was no documentation of IV antibiotics ordered [MEDICAL CONDITION]. Further record review of Resident #1's physician orders [REDACTED]. Further record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Wound MD notes dated 10/12/20 revealed, documentation of a St IV present on admission sacral PU measuring 12 x 10 x 2.5 with an onset date of 9/4/20. Further record review of the Wound MD assessment notes read in part, currently on oral antibiotic for osteo[DIAGNOSES REDACTED] until 10/24/20. There was no documentation of IV antibiotics ordered for osteo[DIAGNOSES REDACTED]. Interview on 10/12/20 at 9:10am with LVN #6, she stated Resident #1 is on three antibiotics, [MEDICATION NAME] 1gm QD, for [DIAGNOSES REDACTED] of her sacral wound, [MEDICATION NAME] 100 mg via PEG BID for 30 days [MEDICAL CONDITION] stating the start date was 9/24/20 and [MEDICATION NAME] 200mg 1 via PEG started on 9/26/20 to 10/24/20 [MEDICAL CONDITION]. She stated she was prescribed [MEDICATION NAME] 1gm/IV BID, but the trough was too high at a value of 27.5 (the trough level is the concentration of the medication in the bloodstream). She said the frequency was changed to 1.5 QD starting on Sunday 10/11/20 until 11/18/20. Interview on 10/12/20 at 9:18am with Resident #1, the resident was lying on her back on a low loss air mattress and wearing heel protectors. She was on continuous humidified O2 via NC at 2 LPM, humidifier bottle labeled 10/10/20. Glucerna 1.2 TF was infusing at 65cc/hr, the TF bottle was initialed and dated 10/12/20. When asked if they are treating her wounds, the resident stated they aren't doing anything. When asked if they turn or reposition her she said no they were not turning her. Observation and interview during wound care on Resident #1 on 10/12/20 at 9:23am with the Wound nurse, ADON, and Wound MD. The Wound nurse stated Resident #1 has five wounds stating a sacral, right buttock, left buttock, right heel and left heel PUs. The soiled dressing to the sacral wound was removed, the soiled dressing was dated 10/11/20 and labeled with the nurses' initials. The wound measured 12cm x 10cm x 2.5cm and was draining bright red blood. There was exposed bone and yellow slough present in the wound base. The wound was cleansed with NS, patted dry, silver alginate was applied, and the wound was covered with a dry absorbent dressing which was labeled with the nurses' initials and dated 10/12/20. Resident #2 Record review of Resident #2's face sheet revealed, an [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Comprehensive MDS dated [DATE] read in part, Section M .Risk of Pressure Ulcers/Injuries: Is this resident at risk of developing pressure ulcers/injuries? Yes was documented. Further record review of Resident #2's Comprehensive MDS revealed, documentation of 1 St III PU present on admission, 1 FA St IV PU , 1 unstageable PU/injury due to non-removable dressing/device, and 1 FA unstageable-Deep tissue injury. Record review of Resident #2's physician orders [REDACTED]. Apply thick layer of Zinc oxide 20%. Also apply PRN, every shift. Further record review of Resident #2's Admission Focused Observation assessment dated [DATE] revealed, Alterations in skin? No was documented. Further record review of the comments read in part, Stage 3 to sacrum area dark pink in color without foul odor. Record review of Resident #2's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? Yes was documented. Further record review of the Weekly Skin Assessment read in part, Skin Tear Location-sacrum, Length- .1 Width- .1 Color of alteration in skin: Red Exudate present? No; Skin Tear Type: No skin loss: linear flap or tear which can be repositioned to cover wound bed. Further record review of Resident #2's physician orders [REDACTED]. Record review of Resident #2's August 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate and Cover with Dry Dressing. Start Date: 8/14/20; DC Date: 9/15/20. Further record review of Resident #2's August 2020 TAR revealed, on 8/14/20 through 8/17/20, 8/19/20, 8/22/20, 8/23/20, 8/24/20, 8/26/20, 8/29/20, 8/30/20, and 8/31/20 no documentation indicating wound care was completed. Further record review of Resident #2's August 2020 TAR read in part, Wound care to sacral area-Stage 3 ulcer clean wound with normal saline, pat dry. Apply thick layer of Zinc oxide 20%. Also apply PRN, every shift. Start Date: 7/25/20; DC Date: 8/18/20. Further record review of Resident #2's August 2020 TAR revealed, on 8/11/20 through 8/17/20 there no documentation indicating wound care was completed. Further record review of Resident #2's Weekly Skin Assessments revealed, there were no weekly skin assessments completed for the weeks of 8/17/20, 8/24/20, 8/31/20, and 9/01/20. Record review of Resident #2's Admission Focused Observation assessment dated [DATE] revealed, Alterations in skin? No was documented. Further record review of the Weekly Wound Tracking Worksheet week of 9/15/20 revealed, Resident #2 was not on the report. Further record review of Resident #2's Weekly Skin assessment dated [DATE], 9/21/20 and 9/28/20 revealed, Alterations in skin? Yes was documented. Further record review of the weekly skin assessm(TRUNCATED)

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to prevent development and worsening of pressure injuries to 3 of 11 residents (CR#1, Resident #1, and Resident#2) reviewed for pressure ulcers. -The facility failed to consistently assess, monitor, and complete wound care as ordered on CR #1's FA St IV right hip and St IV sacral PUs, Resident #1's St IV sacral PU, and Resident #2's FA St IV sacral PU when they opened the quarantine and COVID halls. -The facility failed to ensure there was a designated treatment nurse to manage wounds leaving them to be treated by different nurses who were not properly trained in wound care resulting in CR #1 developing a FA St IV right hip pressure ulcer [MEDICAL CONDITION] of his St IV right hip and sacral pressure ulcers, and worsening and development of osteo[DIAGNOSES REDACTED] in Resident #1 and #2's St IV sacral pressure ulcers. -The facility failed to ensure the Weekly Wound Tracking Worksheets, Weekly Skin assessments, and Wound Management Detail reports were completed and/or accurate to identify new wounds and/or track the progression of CR #1, Resident #1, and Resident #2's PUs. -The facility failed to ensure nursing staff were completing wound care on CR #1, Resident #1, and Resident #2's wounds. -The facility failed to communicate any changes to wounds and/or new wounds identified to the Wound MD. These failures resulted in an immediate jeopardy on 10/15/20. While the IJ was removed on 10/18/20 the facility remained out of compliance at a scope of pattern and a severity of actual harm due to the facility requiring more time to monitor the plan of removal for effectiveness. These failures could affect residents with wounds or who are at risk of developing wounds placing them at risk of infection, a decline in health, pain, and hospitalization . Findings include; CR #1 Record review of CR #1's face sheet revealed, a [AGE] year-old-male originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of CR #1's Care plan edited 10/02/20 read in part, Problem: Problem Start Date: 05/04/20 CR #1 has a pressure ulcer Stage IV to Sacrum .Goal: Resident's ulcer will not increase in size; Approach: Assess the pressure ulcer for location, stage, size, presence /absence of granulation tissue and epithelization . Record review of CR #1's Care Plan problem start edited 10/02/20 read in part, Problem Problem Start Date: 09/16/2020 CR #1 has a pressure ulcer STAGE IV TO R HIP; Goal: Resident's ulcer will heal without complications; Approach: .Assess the pressure ulcer for location, stage, and size, presence/absence of granulation tissue and epithelization .Conduct a systematic skin inspection. Report any signs of further skin breakdown . Record review of the facility's Weekly Wound Tracking Worksheet week of 6/08/20 revealed, CR #1's unstageable sacral PU measuring 3cm x 1.5cm x 1cm present on admission date of [DATE]. Record review of CR #1's physician orders [REDACTED].once a day; 06:00am-10:00pm. Record review of CR #1's June 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate, Cover with Dry Dressing. On 6/17/20 and 6/24/20 there was no documentation indicating wound care was completed. Record review of CR #1's Wound MD assessment notes dated 6/22/20 revealed, a FA unstageable right hip pressure ulcer measuring 2cm x 1cm. Date acquired documented as 6/21/20. Record review of the facility's Weekly Wound Tracking Worksheet week of 6/29/20 revealed, CR #1's St IV facility acquired right hip pressure ulcer measuring 0.2cm x 0.2cm x 0.1cm, with an onset date of 6/21/20. Further record review of the 6/29/20 Weekly report revealed, an unstageable sacral PU present on admission measuring 3cm x 1.5cm x 1cm. Record review of CR #1's physician orders [REDACTED].#1's FA St IV right hip PU. Record review of CR #1's June, July and August 2020 TAR revealed, no treatment orders and/or documentation indicating wound care was completed on his right hip PU. Record review of CR #1's Weekly Wound Tracking Worksheets revealed, two weekly reports for the weeks of 6/08/20 and 6/29/20. The Interim DON could not provide weekly worksheets for the months of May through August 2020 to review. Interview on 10/07/20 at 12:05pm with the Interim DON, she stated the Weekly Wound Tracking worksheets were not completed for the month of August because the Wound nurse was pulled to work on the COVID unit. She said she had the Wound MDs notes for August available for review. When asked if the weekly report was completed in July, she stated yes. Investigator requested the weekly reports for months of May, June and July. Interview on 10/07/20 at 12:39pm with the Interim DON, she stated they looked for the reports further stating they do not have weekly wound reports for the months of May, June, July, and August. She again stated that was the time the wound nurse was pulled to the COVID hall. She said she did locate two weekly reports completed in June. Interview on 10/07/20 at 12:46pm with the Wound Nurse, he said he started working the COVID unit when COVID started around March or April and began working as the wound nurse again the beginning of September end of August. When asked who completed wound care on the non-COVID halls, he stated the floor nurses, but stated he was not sure which nurses did the wound care. When asked how often wound care is completed, he stated wound care is done daily, further stating the floor nurses would have done it daily. Further interview on 10/07/20 at 12:46pm with the Wound Nurse, when asked where wound care is documented once completed, he stated on the TAR. When asked what is documented, he stated the pain score, drainage, color of the wound. He said if they did wound measurements it would be documented on the Wound Management Report. He said wound size, dimensions, and measurements were documented on the Wound Management report. When asked if wound care was documented in the nursing progress notes, he stated occasionally it's documented in the progress notes but mainly it was documented the on wound management report further stating the policy was to document on the wound management report. Record review of CR #1's Wound Management Detail Report dated 6/29/20 revealed, a St III FA right hip PU measuring 0.2cm x 0.2cm x 0.1cm (length x width x depth) with light serous (clear, amber, thin and watery) exudate with 100% granulation tissue. Further record review of the Wound Management Detail Report revealed, documentation indicating the wound resolved on 7/06/20. There were no Wound Management Detail reports for the months of July and August for CR #1's right hip wound. Record review of CR #1's July 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral with NS/WC Pat Dry Apply Calcium Alginate and Cover with Dry Dressing. On 7/4/20, 7/5/20, 7/9/20, 7/12/20, 7/23/20, 7/28/20, 7/29/20, 7/30/20, and 7/31/20 there was no documentation indicating wound care was completed. Record review of CR #1's Wound MD assessment notes dated 7/6/20 revealed, documentation the right hip PU resolved. On 7/12/20, CR #1's Weekly Skin Assessment revealed, documentation of a right hip PU measuring 2cm x 2cm. Record review of CR #1's nursing progress notes dated 7/12/2020 read in part, resident observed with new stage 1 pressure ulcer to right hip. Wound care done, family notified. Record review of CR #1's Weekly Skin assessment dated [DATE], 7/20/20 revealed there was no documentation of the right hip PU. Further record review of CR #1's Wound MD assessment notes dated 7/13/20 revealed, a present on admission St IV sacral PU measuring 3cm x 1cm x 1cm. There was no documentation of a right hip PU. Further record review of CR #1's Wound MD assessment notes revealed, no wound assessments completed for the last two weeks of July. The next wound assessment completed was on 8/03/20. Telephone interview on 10/14/20 at 11:33am with the Wound MD, when asked if he knew if wound care was being completed on residents during the time the quarantine and COVID halls opened, he stated he wasn't sure. He further stated he stayed away from the COVID unit. He said he was out for a two-week period in July because he tested positive. When asked if the facility communicated with him about any concerns or issues with wounds while he was out, he stated no, he had no communication with the facility during that time he was out and again could not state if wound care was being done. Record review of CR #1's dietary progress notes dated 7/23/20 read in part, RD Nut'l Monitoring note/TF/Wound-New: Per latest note new wound R hip (4 wounds) Wt: 126#/BMI: 20.69. Receiving: Decubivite and ACC protein (supplements) . Further record review of CR #1's Weekly Skin Assessments revealed, no skin assessment completed for the week of 7/27/20. Record review of the facility's August Wound Summary Report revealed, CR #1's FA St IV right hip pressure ulcer was not documented on the report. The Interim DON could not provide a Weekly Wound Tracking Worksheet for the month of August. Record review of CR #1's August 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate, Cover with Dry Dressing. On 8/1/20, 8/2/20, 8/4/20, 8/5/20, 8/6/20, 8/13/20, 8/15/20, 8/16/20, 8/24/20, 8/29/20, and 8/30/20 there was no documentation indicating wound care was completed. Record review of CR #1's Weekly Skin Assessments dated 8/03/20, 8/10/20, 8/17/20 revealed there was no documentation of the right hip PU. Further record review of CR #1's Weekly Skin Assessments revealed no weekly skin assessments completed for weeks of 8/24/20 and 8/31/20. Further interview on 10/07/20 at 12:46pm with the Wound Nurse, when asked who was responsible for completing the Weekly skin assessments, he stated he completed all PU related assessments and if the wound is not PU related, the nurses on the floor were responsible for completing the weekly skin assessment, further stating all residents have weekly skin assessments completed. He said the nurses should have been doing the weekly skin assessments when he was working on the COVID unit. He said because he was pulled to work on the quarantine and COVID units, the Weekly Wound Tracking Worksheets were not completed. Record review of CR #1's Wound MD assessment notes dated 8/03/20 revealed, a present on admission St IV sacral PU measuring 2.5cm x 2cm x 1.5cm. There was no documentation of a right hip PU. Further record review of CR #1's Wound MD assessment notes revealed no wound assessments completed on the St IV sacral wound on dates 8/10/20, 8/17/20, 8/24/20, 8/31/20, and 9/28/20. Record review of the Wound Management Detail Report dated 9/02/20, 9/7/20 and 9/14/20 revealed, a FA St IV right hip PU measuring 4cm x 4cm with moderate serous (clear, amber, thin and watery) exudate with 100% slough. Onset date documented as 9/02/20. Record review of CR #1's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? yes was documented. Further record review of the Weekly Skin Assessment comments read in part, Pressure wounds to sacral . TX orders in place There was no documentation of the right hip PU. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/07/20 revealed, CR #1's St IV sacral pressure ulcer measuring 2.5cm x 1.5cm x 1.5cm. The right hip wound was not documented on this weekly wound report. Interview on 10/07/20 at 3:16pm with the Wound nurse, he stated the Wound Management Detail report was completed weekly, stating typically on Mondays. He stated he entered what was on the MDs assessment notes onto this report. When asked during the time he worked on the quarantine and COVID halls, how did he complete the reports for those months when he was not assessing the residents, he stated he inputted the information from the MD notes, stating they were not his wound measurements or descriptions. He stated he does the initial wound measurements on admissions, then uses the Wound MD's measurements after that which are then documented on the Wound Management report. Interview on 10/07/20 at 3:16pm with the Wound Nurse, the investigator showed the Wound nurse the Weekly Wound Tracking Report for CR #1's right hip St IV PU which showed an onset date of 8/10/20, but the right hip wound was not documented on the 9/7/20 report, he stated it was a documentation error and should have been documented on the 9/7/20 report. Record review of CR #1's dietary progress notes dated 9/10/20 read in part, RD Nut'l Monitoring Note/TF/Wound-New: Per latest note new wound R hip (4 wounds) Wt: 128#/BMI:20.69, 2# rebound. Receiving decubivite and protein. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/15/20 revealed, CR'#1 FA St IV right hip pressure ulcer measuring 4cm x 4cm with an onset date of 8/10/20 and a St IV sacral pressure ulcer measuring 3cm x 2.5cm x 1.5cm. Record review of CR #1's Wound Management Detail Report dated 9/21/20 revealed, a St IV FA right hip PU measuring 3cm x 5cm x 1.5cm, with moderate serous (clear, amber, thin and watery) exudate, and 100% slough. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/28/20 revealed, CR #1's St IV right hip facility acquired pressure ulcer measuring 5cm x 6cm x 3cm with an onset date of 8/10/20 and a St IV sacral pressure ulcer measuring 4cm x 3cm x 2.5cm. Record review of the CR #1's Wound Management Detail Report dated 9/28/20 revealed, documentation of a St IV right hip pressure ulcer measuring 5cm x 6cm x 3cm, moderate purulent (opaque, milky; sometimes green) exudate, with necrotic tissue and 50% slough. It further revealed a St IV sacral PU measuring 4cm x 3cm x 2.5cm with moderate serosanguinous (pale, red to pink, thin and watery) exudate. Record review of CR #1's physician orders [REDACTED].Once a day. Further record review of the physician's orders [REDACTED].Once a day. Further record review of CR #1's September 2020 TAR revealed, on 9/20/20 there was no documentation indicating wound care was completed. Further record review of the September 2020 TAR revealed wound care was not ordered until 9/15/20 when the wound was identified on 9/02/20 on the Wound MD assessment notes and was documented as identieid on 8/10/20 on the Weekly Wound Tracking sheet dated 9/28/20. Further record review of CR #1's September 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate, Cover with Dry Dressing. On 9/5/20, 9/6/20, and 9/20/20 there was no documentation indicating wound care was completed. Further interview on 10/07/20 at 3:16pm with the Wound nurse, when asked if the floor nurses were completing daily wound care, and if changes in the wounds were identified, should the details of these changes be documented in the progress notes, weekly skin assessments/observations, and TAR, he said it should be on the observation notes. He stated the nurses should measure the wounds and if there were changes, document the changes on the reports or progress notes. When informed the TAR only requires use of codes to describe the wounds and does not have an area to document measurements, he said measurements should be documented if there are changes. When asked if the Weekly Wound Tracking sheet should be accurate and reflect the correct wound onset dates and wounds identified, he stated yes. Interview on 10/07/20 at 3:28 pm with the Interim DON, when the investigator showed the DON the TARs for the months of June through current date with the multiple blanks spots where wound care should have been documented, she said she can't explain what happened, stating they just completed skin sweeps on all residents. She said she can't explain what happened and why there was no documentation. When asked if she knew if wound care was completed, she could not state. Record review of CR #1's Discharge MDS assessment dated [DATE] revealed he was discharged to an acute hospital on [DATE] with four St IV pressure ulcers, with 1 present on admission/re-admission. Record review of CR #1's hospital progress notes dated 10/01/20 revealed, the resident was admitted to the hospital with [REDACTED]. Record review of CR #1's Emergency Department Provider Documentation dated 10/01/20 read in part, .History obtained from previous records as none was given by EMS or transferring facility. He is hypotensive. Actively bleeding from right hip decubitus ulcer. All wounds evaluated, clean, and redressed by myself, with surgical packed to bleeding wound. Septic work-up ordered. Patient's (family member) here .she is unsure of when bleeding to right hip started, as she was not notified . Record review of CR #1's Radiology report dated 10/01/20 read in part, Impression: 1. Decubitus ulcer in the lower sacrum with adjacent cortical erosion of the S1 concerning for osteo[DIAGNOSES REDACTED] (an infection of the bone). 2. Decubitus ulcer on the lateral aspect of the right gluteal region with adjacent soft tissue [MEDICAL CONDITION]. There is adjacent cortical erosion of the S1 .concerning for osteo[DIAGNOSES REDACTED] . Resident #1 Record review of Resident #1's face sheet revealed, a [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #1 Quarterly MDS dated [DATE] read in part, Section M .Risk of Pressure Ulcers/Injuries: Is this resident at risk of developing pressure ulcers/injuries? Yes was documented. Further record review of Resident #1's Quarterly MDS revealed, documentation of 1 Stage 2 PU present on admission, 2 stage 3 PUs present on admission, and 1 Stage IV PU present on admission. Record review of Resident #1's Admission assessment dated [DATE] revealed, Alterations in skin? No was documented. Further record review of the Admission Assessment comments read in part, Stage 3 sacral pu. Record review of Resident #1's Admission assessment dated [DATE] revealed, Alterations in skin? Yes documented. Further record review of the Admission Assessment read in part, Wound Location- sacrum; Length .3.5 (cm); Width .3 (cm) . Record review of Resident #1's Focused Observation dated 8/12/20 revealed, Alterations in skin? Yes was documented. Further record review of the Focused Observation read in part, Ulcer; Location: sacrum, Length: . 12(cm); Width: . 10.5 (cm) .Wound/Ulcer type: Pressure ulcer; Stage: Unstageable: Slough and/or Eschar; .Depth of tissue injury: Full thickness: Through dermis & down to subq tissue, muscle; Wound bed descriptions: Tissue Type and Color: Slough: yellow, green, gray, nonviable (necrotic) tissue, usually light in color, thin, wet stringy .Date Wound Identified: 07/28/2020 . Record review of the facility's Weekly Wound Tracking Worksheet week revealed no reports for the months of July and August 2020 to review for Resident #1. Record review of Resident #1's Focused Observation; Weekly skin dated 8/27/20 revealed, Alterations in skin? Yes was documented. Further record review of the Focused Observation; Weekly skin read in part, Wound Location-sacrum; Length .15 (cm); Width .10 (cm) . Record review of Resident #1's August 2020 TAR read in part, Daily Wound Treatment: Sacral. Cleanse wound with NC/WC Pat Dry Apply Santyl and Calcium Alginate, Cover with Dry Dressing Daily. Further record review of Resident #1's August 2020 TAR revealed, on 8/13/20, 8/14/20, 8/15/20, 8/16/20, 8/17/20, 8/24/20, 8/29/20, 8/30/20, and 8/31/20 there was no documentation indicating wound care was completed. Further record Review of Resident #1's Focused Observation; Weekly skin dated 9/3/20 and 9/07/20 revealed, Alterations in skin? Yes was documented. Further record review of the Focused Observation; Weekly skin comments revealed she had a sacral wound. Record review of Resident #1's Care plan edit date 10/12/20 read in part, Problem: Problem Start Date: 9/08/2020 Resident has a pressure ulcer STAGE IV TO SACRAL; Goal: Resident's ulcer will heal without complications; Approach: Assess the pressure ulcer for location, stage, size (length, width, and depth), presence/absence of granulation tissue and epithelization WEEKLY. Conduct a systematic skin inspection WEEKLY. Report any signs of any further skin breakdown . There was no documentation of osteo[DIAGNOSES REDACTED] with PO antibiotics or IV antibiotic treatment for [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Further record review of Resident #1' physician orders [REDACTED]. Cleanse Wound with NS/WC Pat Dry Apply Silver Alginate Cover with Dry Dressing Daily. Once a Day 06:00AM-10:00PM Record review of Resident #1's September 2020 TAR revealed, on 9/5/20 and 9/6/20 there was no documentation indicating wound care was completed on her sacrum. Record review of Resident #1's Readmission Focused Observation dated 9/23/20 revealed, Alterations in skin? Yes was documented. Further record review of the Readmission Focused Observation comments read in part, Resident has pressure wound to sacral at 11 (cm) x 10 (cm) x 2.5 (cm), R buttocks at 3 (cm) x 1.5 (cm) . Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? Yes was documented. Further record review of the Weekly Skin assessment comments read in part, Resident has pressure ulcer wound to sacral, R buttocks . Record review of the facility's Weekly Wound Tracking Worksheet week of 9/7/20 revealed, a community acquired St IV sacral PU measuring 7cm x 10cm with an onset date of 7/28/20. Record review of the facility's Weekly Wound Tracking Worksheet week of 9/28/20 revealed, a community acquired St IV sacral PU measuring 10cm x 11cm x 3cm with an onset date of 9/4/20. Interview on 10/07/20 at 3:16pm with the Wound Nurse, when the investigator showed the treatment nurse the Weekly Wound Tracking report for weeks of 9/28/20 for Resident #1s St IV Sacral PU which had an onset date of 9/4/20, then on the Weekly Wound Tracking report week of 9/7/20, the onset date was documented 7/28/20. He stated that was also a documentation error, further stating she was admitted with a sacral wound on 7/28/20, stating the onset date should be 7/28/20. Record review of Resident #1's Wound MD notes dated 9/28/20 revealed, documentation of a St IV present on admission sacral PU measuring 10cm x 11cm x 3cm with an onset date of 9/4/20. Further record review of the Wound MD assessment notes read in part, 25% necrotic bone currently on oral antibiotic for osteo[DIAGNOSES REDACTED] until 10/24/20. There was no documentation of the IV antibiotic ordered [MEDICAL CONDITION]. Further record review of Resident #1's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? Yes was documented. Further record review of the Weekly Skin assessment comments section read in part, Resident has pressure ulcer wound to sacral, R buttocks, L buttocks . Record review of the facility's Weekly Wound Tracking Worksheet week of 10/05/20 revealed Resident #1 had a community acquired St IV sacral PU measuring 11cm x 11cm x 3cm with an onset date of 9/4/20. Record review of Resident #1's Wound Management Detail Report dated 10/05/20 revealed, a St IV sacral PU present on Admission/Re-entry measuring 11cm x 11cm x 3cm with moderate serous (clear, amber, tin and watery) exudate with 25% slough and 75% granulation tissue. The date identified was documented 8/10/20. Record review of Resident #1's Wound MD notes dated 10/05/20 revealed, documentation of a St IV present on admission sacral PU measuring 11cm x 11cm x 3cm with an onset date of 9/4/20. Further record review of the Wound MD assessment notes read in part, currently on oral antibiotic for osteo[DIAGNOSES REDACTED] until 10/24/20. There was no documentation of IV antibiotics ordered [MEDICAL CONDITION]. Further record review of Resident #1's physician orders [REDACTED]. Further record review of Resident #1's physician orders [REDACTED]. Record review of Resident #1's Wound MD notes dated 10/12/20 revealed, documentation of a St IV present on admission sacral PU measuring 12 x 10 x 2.5 with an onset date of 9/4/20. Further record review of the Wound MD assessment notes read in part, currently on oral antibiotic for osteo[DIAGNOSES REDACTED] until 10/24/20. There was no documentation of IV antibiotics ordered for osteo[DIAGNOSES REDACTED]. Interview on 10/12/20 at 9:10am with LVN #6, she stated Resident #1 is on three antibiotics, [MEDICATION NAME] 1gm QD, for [DIAGNOSES REDACTED] of her sacral wound, [MEDICATION NAME] 100 mg via PEG BID for 30 days [MEDICAL CONDITION] stating the start date was 9/24/20 and [MEDICATION NAME] 200mg 1 via PEG started on 9/26/20 to 10/24/20 [MEDICAL CONDITION]. She stated she was prescribed [MEDICATION NAME] 1gm/IV BID, but the trough was too high at a value of 27.5 (the trough level is the concentration of the medication in the bloodstream). She said the frequency was changed to 1.5 QD starting on Sunday 10/11/20 until 11/18/20. Interview on 10/12/20 at 9:18am with Resident #1, the resident was lying on her back on a low loss air mattress and wearing heel protectors. She was on continuous humidified O2 via NC at 2 LPM, humidifier bottle labeled 10/10/20. Glucerna 1.2 TF was infusing at 65cc/hr, the TF bottle was initialed and dated 10/12/20. When asked if they are treating her wounds, the resident stated they aren't doing anything. When asked if they turn or reposition her she said no they were not turning her. Observation and interview during wound care on Resident #1 on 10/12/20 at 9:23am with the Wound nurse, ADON, and Wound MD. The Wound nurse stated Resident #1 has five wounds stating a sacral, right buttock, left buttock, right heel and left heel PUs. The soiled dressing to the sacral wound was removed, the soiled dressing was dated 10/11/20 and labeled with the nurses' initials. The wound measured 12cm x 10cm x 2.5cm and was draining bright red blood. There was exposed bone and yellow slough present in the wound base. The wound was cleansed with NS, patted dry, silver alginate was applied, and the wound was covered with a dry absorbent dressing which was labeled with the nurses' initials and dated 10/12/20. Resident #2 Record review of Resident #2's face sheet revealed, an [AGE] year-old-female originally admitted on [DATE] and re-admitted on [DATE] with [DIAGNOSES REDACTED]. Record review of Resident #2's Comprehensive MDS dated [DATE] read in part, Section M .Risk of Pressure Ulcers/Injuries: Is this resident at risk of developing pressure ulcers/injuries? Yes was documented. Further record review of Resident #2's Comprehensive MDS revealed, documentation of 1 St III PU present on admission, 1 FA St IV PU , 1 unstageable PU/injury due to non-removable dressing/device, and 1 FA unstageable-Deep tissue injury. Record review of Resident #2's physician orders [REDACTED]. Apply thick layer of Zinc oxide 20%. Also apply PRN, every shift. Further record review of Resident #2's Admission Focused Observation assessment dated [DATE] revealed, Alterations in skin? No was documented. Further record review of the comments read in part, Stage 3 to sacrum area dark pink in color without foul odor. Record review of Resident #2's Weekly Skin assessment dated [DATE] revealed, Alterations in skin? Yes was documented. Further record review of the Weekly Skin Assessment read in part, Skin Tear Location-sacrum, Length- .1 Width- .1 Color of alteration in skin: Red Exudate present? No; Skin Tear Type: No skin loss: linear flap or tear which can be repositioned to cover wound bed. Further record review of Resident #2's physician orders [REDACTED]. Record review of Resident #2's August 2020 TAR read in part, Daily Wound Treatment: Cleanse Wound to Sacral With NS/WC Pat Dry Apply Calcium Alginate and Cover with Dry Dressing. Start Date: 8/14/20; DC Date: 9/15/20. Further record review of Resident #2's August 2020 TAR revealed, on 8/14/20 through 8/17/20, 8/19/20, 8/22/20, 8/23/20, 8/24/20, 8/26/20, 8/29/20, 8/30/20, and 8/31/20 no documentation indicating wound care was completed. Further record review of Resident #2's August 2020 TAR read in part, Wound care to sacral area-Stage 3 ulcer clean wound with normal saline, pat dry. Apply thick layer of Zinc oxide 20%. Also apply PRN, every shift. Start Date: 7/25/20; DC Date: 8/18/20. Further record review of Resident #2's August 2020 TAR revealed, on 8/11/20 through 8/17/20 there no documentation indicating wound care was completed. Further record review of Resident #2's Weekly Skin Assessments revealed, there were no w(TRUNCATED)

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment including the use of PPE and following CDC guidelines for COVID-19 for 10 of 10 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) reviewed for infection control. -The facility failed to use appropriate PPE, including protective gowns, when providing care for newly admitted and readmitted residents. -The facility failed to have PPE set up outside of quarantined rooms for staff to don prior to entering the room. The rooms did not have signage on the door to indicate the residents were on quarantine. -The facility failed to monitor quarantined residents for signs and symptoms of COVID-19 every shift as recommended by the CDC. -The facility failed to quarantine five [MEDICAL TREATMENT] residents who left the facility multiple days per week for treatment. There was no PPE set up on the doorways for staff to don prior to entering the room. An Immediate Jeopardy (IJ) was identified on 5/29/20. While the IJ was removed on 6/3/20 the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of pattern while they continued to monitor their plan of removal. These failures placed all residents in the facility at risk of contracting an infectious disease. Findings Include: Record review of the Admit/Discharge Report dated 5/29/20 revealed the following residents were on a 14-day quarantine: -New Admission: Resident #1 admitted on [DATE]. -Readmission: Resident #2 admitted on [DATE], Resident #3 admitted [DATE], Resident #4 admitted [DATE] Resident #5 admitted [DATE]. -[MEDICAL TREATMENT] residents on continuous quarantine Resident #6 Resident #7 Resident #8 Resident #9 Resident #10. Resident #1 Record review of Resident #1's face sheet revealed a [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #1's current MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. She needed extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of Resident #1's care plan dated 5/21/20 read in part, . Problem: (Resident #1) is at risk for alteration in Psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan . Approach: . provide preferred in room activities . Observation on 5/29/20 at 10:23 a.m. of Resident #1 in her room on 300 hall revealed she was in a single room and door was open to the hallway. There was no PPE set up or signage near her door that indicated she was on quarantine, and no hazard bins for trash or linen in the room. Resident #1 put on her call light for assistance for a brief change. RA A wearing a N-95 mask responded to the call light and entered Resident #1's room without donning a gown and donned gloves when she entered the room. After providing care, RA A exited Resident #1's room holding a clear trash bag containing the resident's dirty brief, gloves, and wipes and placed the trash in the 300 hall trash room. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, . HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection . Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Interview on 5/29/20 at 10:29 a.m. with RA A, she said she was not assigned to any hallway or resident but would assist with answering call lights throughout the entire facility. She said Resident #1 was not on quarantine or isolation and did not require any special PPE. She said if special PPE were needed, signage would be on the door. She said the [MEDICAL TREATMENT] residents were ion quarantine on 100 hall. Observation on 5/29/20 at 2:25 p.m. of Resident #1 revealed she was in the therapy room on an exercise bike with two other residents present in the room. Resident #1 was not wearing a mask. Interview at the same time with the Physical Therapist, she said this was Resident #1's first day in the therapy room. She said therapy was previously done in Resident #1's room because she was on quarantine for 14 days. Resident #2 Record review of Resident #2's face sheet revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #2's current MDS dated [DATE] revealed a staff assessment for mental status was completed and indicated the resident had a memory problem and modified independence for daily decision making. She needed extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of Resident #2's care plan dated 5/21/20 read in part, . Problem: (Resident #2's) psycho-social well being is at risk r/t readmission quarantine due to COVID-19 . Approach: Monitor for psycho-social changes . Observation on 5/29/20 at 10:11 a.m. revealed Resident #2 in a single room on the 400 hall. There was no PPE set up near the doorway or biohazard bins in the room, and no signage indicating that the resident was on quarantine. Interview on 5/29/20 at 10:25 a.m. with RN A, she said no residents were on isolation and there were no isolation precautions in place. She said Resident #2 was on quarantine because she just returned from the hospital. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, . HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection . Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Resident #3 Record review of Resident #3's face sheet revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #3's current MDS dated [DATE] revealed a staff assessment for mental status was completed, indicated the residents' memory was not impaired, and was modified independent for daily decision making. He needed extensive assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. Record review of Resident #3's care plan dated 5/21/20 read in part, . Problem: (Resident #3's) psycho-social well-being is at risk r/t readmission quarantine due to COVID-19 . Record review of Resident #3's Physician order [REDACTED]. HD ([MEDICAL TREATMENT]) . every MON-WED-FRI . start date 4/27/20 . Observation on 5/29/20 at 9:20 a.m. of Resident #3 sitting in a single room on the 500 hall. There was no PPE set up near his room or signs indicating the resident was on quarantine. CNA B wearing a N-95 mask walked in to Resident #3's room without a gown or gloves on to remove his breakfast tray. Resident #3's tray contained regular silverware, cups, plate, and plate cover and the tray was placed on a cart with the other resident's trays. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, . HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection . Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures . Interview on 5/29/20 at the same time with CNA B, she said Resident #3 was on quarantine because he was a [MEDICAL TREATMENT] resident. She said he leaves the facility on Tuesdays, Thursdays, and Saturdays. She said he received regular trays. Continued interview on 5/29/20 at 10:06 a.m. with CNA B, she said Resident #3 was the only resident on her hall (500 hall) on quarantine. She said the difference between quarantine and isolation was with isolation you must wear PPE. She said she did not have to use PPE when caring for quarantined residents. She said she had been trained on PPE. She said she removed linen for quarantined residents as normal and placed it with other resident's linens. The linen would be removed from the room and moved to soiled utility room. She said the quarantined trash was removed as normal. She said if a resident was on isolation, their linen would be placed in a red bag and their trash would be placed in a biohazard box. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, . HCP who enter the room of a patient with known or suspected COVID-19 should adhere to Standard Precautions and use a respirator (or facemask if a respirator is not available), gown, gloves, and eye protection . Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Resident #4 Record review of Resident #4's face sheet revealed a [AGE] year-old male originally admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #4's current MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. He needed extensive assistance of one person for bed mobility, dressing, toilet use, and personal hygiene. Record review of Resident #4's care plan dated 4/24/20 read in part, . Problem: (Resident #4) is at risk for alteration in psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan . Interview on 5/29/20 at 9:40 a.m. with Housekeeper A, she said she was not aware of any residents on isolation or quarantine and did not know who the [MEDICAL TREATMENT] residents were. She said if residents were on isolation or quarantine she would clean the rooms the same way. She said she was trained on appropriate use of PPE. She said she cleaned rooms and wiped rails around the building. She said she takes trash out frequently. Observation on 5/29/20 at 10:03 a.m. revealed Resident #4 was lying in bed in a single room on the 300 hall. The door was opened to the hallway. There was no PPE set up on the doorway or signage to indicate the resident was on quarantine. There were no hazard bins in the room to discard trash and linen. There was a glass of orange juice and a glass of tea in the resident's room. Housekeeper A entered the room wearing a N-95 mask and gloves and did not don a gown. She removed a clear trash bag from the trashcan, which contained gloves, and placed it in the housekeeping cart trash. Housekeeper A wiped down Resident #4's room door handles, bedside tray, bathroom, mopped and swept the room floor. Interview on 5/29/20 at 10:10 a.m. with Housekeeper A, as she placed the dirty mopping cloth in a clear bag which she said would go to the laundry room. Housekeeper A said she would take the trash from her cart out to the dumpster. She said after she cleaned Resident #4's room, she would go the next resident room to clean on 300 hall. She said she uses a new cloth in each room. She said she did not clean rooms in a certain order but would zig zag from room to room. She said if a resident was on quarantine there would be gown and gloves on the doorway. She said she had to use PPE if it was placed on the doorway. She said she cleaned the 100 hall first and then the 300 hall. She said she used the same broom on the resident rooms and had not sanitized the brushes. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Routine cleaning and disinfection procedures (e.g., using cleaners and water to pre-clean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) . Resident #5 Record review of Resident #5's face sheet revealed a [AGE] year-old male originally admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #5's current MDS dated [DATE] revealed the BIMS score and staff assessment for mental status were blank. He needed extensive assistance with bed mobility, dressing, and personal hygiene, and was totally dependent with eating and toilet use. Record review of Resident #5's care plan dated 5/21/20 read in part, . Problem: (Resident #5's) psycho-social well-being is at risk r/t readmission quarantine due to COVID-19 . Observation on 5/29/20 at 10:11 a.m. of Resident #5's in a single room on the 400 hall. There was no PPE set up near the doorway or biohazard bins in the room, and no signage indicating that the resident was on quarantine. Observation on 5/29/20 at 10:16 a.m. of RN A, she entered Resident #5's room wearing a N-95 mask and did not don a gown or gloves. Interview on 5/29/20 at 10:25 a.m. with RN A, she said no residents were on isolation and there were no isolation precautions in place. She said Resident #5 was on quarantine because he just returned from the hospital. She said PPE was not required when entering quarantined residents' rooms. She said at this time all staff wore masks while in the facility. She said the quarantined residents could not leave their rooms and she monitored them for symptoms of COVID-19. She had been trained on PPE and was assigned to work the entire 400 hall. Resident #6 Record review of Resident #6's face sheet revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #6's current MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. He needed supervision of one staff for bed mobility and limited assistance with one staff for dressing. Record review of Resident #6's Physician order [REDACTED]. HD ([MEDICAL TREATMENT]) . every TUE, THUR, SAT . start date 1/26/20 . Observation on 5/29/20 at 10:44 a.m. of Resident #6's in a single room on the 100 hall. The door was open and there was no PPE set up on the doorway or signage indicating the resident was on quarantine, and there were no biohazard bags in the bathroom or room. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Resident #7 Record review of Resident #7's face sheet revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #7's current MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate cognitive impairment. She needed supervision of one staff for bed mobility, transfers, eating, and toilet use; and limited assistance od one staff for dressing. Record review of Resident #7's Physician order [REDACTED]. HD ([MEDICAL TREATMENT]) . every MON-WED-FRI . start date 7/28/19 . Record review of Resident #7's care plan dated 5/12/20 read in part, .Problem (Resident #7) is at risk for alteration in psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan . Observation on 5/29/20 at 9:59 a.m. of Resident #7's in a single room on the 100 hall. There was no PPE set up on the doorway or sign that the resident was on quarantine, and there were no biohazard bags in the bathroom or room. Resident #8 Record review of Resident #8's face sheet revealed a [AGE] year-old female admitted on [DATE] and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. Record review of Resident #8's current MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate cognitive impairment. She needed extensive assistance of one staff for bed mobility, dressing, and personal hygiene; and was totally dependent on one staff for toilet use. Record review of Resident #8's Physician order [REDACTED]. HD ([MEDICAL TREATMENT]) . every TUE, THUR, SAT . start date 4/24/20 . Record review of Resident #8's care plan read in part, . Problem: (Resident #8) is at risk for alteration in psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan . Observation on 5/29/20 at 10:40 a.m. of Resident #8 who was lying in bed in a single room on the 100 hall. The door was open to the hallway with no PPE set up on the doorway or signage indicating the resident was on quarantine. There were no biohazard bags in the bathroom or room. Resident #9 Record review of Resident #9's face sheet revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #9's most current MDS assessment dated [DATE] revealed a BIMS score of 14 out of 15 indicating intact cognition. He needed extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and supervision of one staff for eating. Record review of Resident #9's Physician order [REDACTED]. HD ([MEDICAL TREATMENT]) . every TUE, THUR, SAT . start date 7/28/19 . Record review of Resident #9's care plan dated 3/12/20 read in part, . Problem: (Resident #9) is at risk for alteration in psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan Record review of Resident #10's care plan dated 5/14/20 read in part, .Problem: (Resident #10) is at risk for alteration in psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan . . Observation on 5/29/20 at 10:11 a.m. of Resident #9's in a single room on the 400 hall. There was no PPE set up near the doorway or biohazard bins in the room, and there was no signage indicating the resident was on quarantine. Resident #10 Record review of Resident #10's face sheet revealed a [AGE] year-old male admitted on [DATE] and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Record review of Resident #10's current MDS dated [DATE] revealed a BIMS score of 6 out of 15 indicating severe cognitive impairment. He needed extensive help of one staff for bed mobility, dressing, personal hygiene, and was totally dependent on one staff for transfers. Record review of Resident #10's Physician order [REDACTED]. HD ([MEDICAL TREATMENT]) . every T, TH, Saturday . start date 2/1/20 . Record review of Resident #10's care plan dated 5/14/20 read in part, .Problem: (Resident #10) is at risk for alteration in psychosocial well-being related to restriction on visitation and group activities due to the COVID-19 prevention and response plan . Observation on 5/29/20 at 10:00 a.m. of Resident #10's room on the 500 hall. There was no PPE set up on the doorway or no signs indicating the resident was on quarantine. There were no biohazard bins in the room for linen or trash. Interview on 5/29/20 at 10:06 a.m. with CNA B, she said Resident #10 was on quarantine because he went to [MEDICAL TREATMENT]. Interview on 5/29/20 at 11:30 a.m. with LVN A, she said she was working with all residents (Quarantined and non quarantined) on the 100, 300, and 500 halls. She said no resident under her care was on isolation. She said the quarantined residents under her care were Residents #1, #3, #4, #6, #8, and #10. She said residents who were new admissions, readmissions, or went to [MEDICAL TREATMENT] were on quarantine. She said the residents on quarantine did not require any special precautions when providing care, only to wear a mask and perform hand hygiene. She said protective gowns were not required because the residents were not on isolation. She said the quarantined residents were provided with masks. She said the residents on quarantine did not use Styrofoam plates nor did they have biohazard bins in their rooms. She said all resident vitals were conducted once a day. Interview on 5/29/20 at 11:42 a.m. with the Dietary Director, she said disposable dishware was not in use because no resident was on isolation or quarantine. She said disposable dishware was on hand if needed. She said the DON would inform her if a resident required disposable dishware. Interview on 5/29/20 at 12:05 p.m. with the DON, she said new admission and readmission residents were on quarantine for 14 days. She said [MEDICAL TREATMENT] residents were on continuous quarantine and were provided a N-95 mask when leaving their room or the facility. She said quarantined residents were at higher risk for being around someone who could be positive for COVID-19. She said new residents who had a negative COVID-19 result had to quarantine for 14 days because they could have been exposed from the date of the test to the day they entered the facility. She said it was O.K. that quarantined residents were spread throughout the facility on the 100, 300, 400, and 500 halls because they were in single rooms. The quarantined residents were placed in a single room and monitored by staff once a day for vitals, temperature, signs and symptoms of COVID-19, coughing, and sweats. She said her policy did not say temperatures had to be taken every shift. She said staff were expected to wear N-95 masks and gloves and follow handwashing when providing care for quarantined residents. She said staff were not required to wear gowns in quarantined rooms because the resident was not on isolation and it would be wasted use of PPE. She said the quarantined residents were not symptomatic of COVID-19 and there were no positive cases in the facility. She said gowns would provide protection for clothes, but clothes should be washed every day. She said any resident was potentially positive for COVID-19 and the residents at higher risk (new admissions, readmissions, and [MEDICAL TREATMENT]) were not treated different from the residents who do not leave the facility. She said [MEDICAL TREATMENT] residents were not more at risk than anyone else for COVID-19. She said the [MEDICAL TREATMENT] residents were alert and could tell staff if they felt different. She said staff were expected to notify the nurse if a quarantined resident developed a fever, chills, or headache. If symptomatic, the staff would don full protective equipment, notify MD, isolate the resident, set up isolation bins, and act like the resident is positive for COVID-19. She said nursing staff were working in the same general areas and Medication and Restorative aides worked with all the residents. She said the facility used regular dishware with quarantined residents because the heat used to clean dishes should kill any virus. She said there was no special precautions for quarantined resident's trash or linen. Linen was washed as normal because the hot water should kill the infection. She said there were no special precautions with the way housekeeping cleaned the quarantined resident's rooms. She said if the facility had a positive COVID-19 case, designated staff would work with the resident. Interview on 5/29/20 at 12:38 p.m. with the Administrator, he said new admissions and hospital readmissions were placed on a 14-day quarantine, and [MEDICAL TREATMENT] residents stayed on quarantine. He said the residents were quarantined because they had gone out of the facility. He said they would be treated as potentially positive for COVID-19 but were not a true positive. He said new admissions were placed on the 100 or 300 hall in a private rooms. Residents who returned from the hospital remained in their previous room if they did not have roommate. If they had a roommate, the readmitted resident would be moved to a new room. He said [MEDICAL TREATMENT] residents were also in a private rooms. He said he informed new admission and readmission residents that they would be on a 14-day quarantine, provided them with a N-95 mask, and encouraged them to stay in their rooms. He said if residents were seen out of their room they would be redirected to their room. He said staff wore gloves and a N-95 mask when providing care for quarantined residents. He said staff did not wear gowns in quarantined residents' rooms because it was not required per their quarantine policy. He said quarantined residents' linen and trash were maintained the same as other residents. Quarantined residents' linen would be washed with non-quarantined residents' linen. He said paper plates were not used for quarantined residents because they were not on isolation and it could be considered a dignity issue. He said vitals and signs and symptoms for COVID-19 were checked daily according to their policy. He said if a resident became symptomatic for COVID-19 or had a positive test he would place them on isolation on the 200 hall. Residents on isolation would require gowns and designated staff would be assigned at that time. The Administrator said COVID-19 could spread without symptoms. He said if staff were required to wear gowns when caring for residents on quarantine, all staff would have to wear full PPE on every resident because everyone (residents and staff) were considered at risk for COVID-19. He said he stayed up to date with the Nursing Facility State Response Plan and CDC guidance. He said as of 5/29/20, all 61 residents were tested for COVID-19. He said the results were 59 tested residents were negative and two residents were retested on [DATE] because their previous test was rejected. He said approximately 84 staff were tested and the results were negative. Interview on 5/21/20 at 12:58 p.m. with LVN G, she said all resident temperatures and vitals were taken once a day. She said she was told everybody needed a temperature once a day. She said she had not been told to take temperatures every shift. Continued interview at 1:15 p.m. with the Administrator, he said the facility had an adequate supply of PPE including N-95 masks, gowns, and gloves. The Administrator said the residents were not symptomatic for COVID-19 and everyone was at risk for COVID-19. He said staff did wear an N-95 mask and gloves. Interview on 5/21/20 at 2:15 with the Administrator, he reviewed the HHS COVID 19 Response Plan for Nursing Homes and said technically everyone had unknown COVID-19 status. Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, Position a trash can near the exit inside the resident room to make it easy for staff to discard PPE prior to exiting the room . Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures . Record review of Preparing for COVID-19 in Nursing Homes www.cdc.gov dated May 19, 2020 read in part, . Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown . Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area, so the resident can be monitored for evidence of COVID-19. HCP should wear an N-95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. Testing at the end of this period can be considered to increase certainty that the resident is not infected . Record review of the facility's Accepting and Transferring Patients/Residents policy with no date read in part, . New and Returning patients/residents that tested negative during a recent acute care stay, can be transferred to a long-term care facility after discharge from the hospital. The following must be implemented: 1. The patients/resident should be placed on a 14-day quarantine on admission from the hospital. 2. Transmission Based Precautions (TBP) for at least 7 days from the date of the negative COVID-19 test. OR 3. Or at least three (3) days have passed since the resident has had a fever without the use of fever reducing medications and does not exhibit any signs of respiratory symptoms . Patients/Residents with No Clinical Concerns for COVID-19 . 1. The patient/resident should be placed on a 14-day quarantine on admission from the hospital 2. Based on the facilities status (respiratory illness present) The resident screening tool should be completed daily for non-respiratory illness facilities, and twice a day for facilities with respiratory illness-on all patients/residents .Things to Remember: 1. Patients/residents on therapy must have therapy completed in their room if they are on isolation and/or quarantine . Record review of the facility's Infection Prevention and Control Policies and Procedures: policy dated 11/27/17 read in part, . Subject: isolation /precautions including standard/universal precautions . 3. Transmission-based isolation . B. Three types of Transmission-Based Precautions 1. Airborne isolation 2. Droplet isolation. 3. Contact Isolation C. Used in addition to Standard Precautions, when needed . 4. Rationale for Transmission-Based Isolation: . B. Source: 1. Human sources of infecting microorganisms may be patients/residents, personnel, or visitors. 2. May include: . b. persons in the incubation period of a disease . Record review of the facility's Coronavirus Disease 2019 (COVID-19) Pandemic Prevention and Response Plan revised 4/15/2020 read in part, . Infection Preventionist . 3. Monitors CDC recommendations for pandemic prevention and response communicating pertinent information to key committee members . Record review of Harris County Public Health Department https://publichealth.harriscountytx.gov/Resources/2019-Novel-Coronavirus revealed from 5/21/20 to 6/3/20 there were a total of 1,366 new cases in Harris County. These failures resulted in an Immediate Jeopardy (IJ). The Administrator was notified of the IJ on 5/29/20 at 4:44 p.m. and a plan of remova (TRUNCATED)