Every finding on record at Cypress Pointe Rehabilitation and Nursing

Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide adequate supervision to prevent accidents for 1 of 45 residents (Resident #95), in the survey sample which constituted harm.The findings included: The facility staff failed to provide adequate supervision to ensure Resident #95 was safe from falling while providing activities of daily living (ADL) care which constituted harm.Resident #95 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #95 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included unspecified dementia without behavioral disturbance, major depressive disorder, and muscle weakness. Resident #95 was coded as rarely/never understood so there was no Brief Interview for Mental Status (BIMS) completed.A synopsis of an event dated 2/25/25 revealed that Resident #95 had a witnessed fall while a Certified Nursing Assistant (CNA) was providing activities of daily living (ADL) care. The CNA turned around to rinse a wash cloth and the resident rolled out of the bed on left side and fell to the floor. The resident was diagnosed with the following: a distal fibular fracture and tibial fracture.A review of section GG (Functional Abilities and Goals) dated 1/4/25 of Resident #95's Minimum Data Set (MDS) coded the resident as dependent (helper does all of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity) for Roll left and right: The ability to roll from lying on back to left and right side, and return to lying on back on the bed.A review of Resident #95's nurses note dated 2/25/25 at 1:00 PM read: Resident received in bed alert with eyes opened. Resident had a witnessed fall from bed. Resident was in bed receiving adl care via aid. Aid turned around for a second to rinse wash cloth and resident rolled out of bed onto left side, per aid. Aid called out from resident's room. Resident was assessed head to toe; small skin noted to left lower arm area. Vital signs taken, resident moved to safe position in bed with bed low and mats to bedside floor. Md made aware, um made aware, JFS Shakayla made aware. Risk management completed. No signs of distress at this time. No signs of pain nor facial grimacing at this time. Respirations even and unlabored. Will advise oncoming nurse.A review of Resident #95's nurses note dated 2/26/25 at 8:47 PM read: Perimeter overlay was placed on the resident's mattress.A review of Resident #95's nurses note dated 2/28/25 at 3:34 PM read: Supervisor on duty made aware and witnessed the resident's bilateral lower leg was swollen had a bruised on (R) anterior ankle. N/P on-call was called and recieved a New order- - Acetaminophen 325mg 2tabs PRN by mouth Q/6hrs. - X-ray on bilateral legs , Call and inform first the family or close relative/ if they will approved it since Resident was on comfort care.A review of Resident #95's nurses note dated 2/28/25 at 10:31 PM read: Resident's bilateral ankle swollen w/ bruised observed, and obviously Pt. in pain while doing ADL care. U/M aware and N/P on call informed. N/O for PRN Acetaminophen 325mg 2 tabs. by mouth to be given PRN at Q6/hr. X-ray was also ordered (bilateral ankle) r/t swollen, Conditionally informing family members/ near relative or hospice if they will allow it. Hospice called 8:20pm and awaiting for confirmation. Endorse to the next on-coming shift Nurse.A review of Resident #95's nurses note dated 3/3/25 at 6:53 AM read: Resident has edema and bruising to BLE, no s/s of distress at this time. Resident legs are elevated on pillows while in bed.A review of Resident #95's nurses note dated 3/3/25 at 4:02 PM read: This order is outside of the recommended dose or frequency. Morphine Sulfate (Concentrate) Solution 20 MG/ML *Controlled Drug* Give 5 milligram by mouth every 4 hours as needed for Pain - This dose fails a general dose range check based on drug inputs and/or the patient information provided. This drug`s dose should be adjusted based on renal function. Manual screening is required.A review of Resident #95's nurses note dated 3/3/25 at 7:10 PM read: X-ray Technician in this facility to do x-ray of bi-lateral feet and ankle awaiting results.:A review of Resident #95's nurses note dated 3/3/25 at 7:56 PM read: Xray bilateral ankles and feet DX: h/o fall: new bruising and swelling STAT for h/o Fall: bruising/swelling X-Ray-done 5:20pm, Awaiting for results.A review of Resident #95's nurses note dated 3/4/25 at 7:23 AM read: LEFT FOOT AND LEFT ANKLE X-RAY RESULTS: ACUTE LOOKING FRACTURES OF DISTAL TIBIA AND FIBULA ARE NOTED WITH POSTERIOR AND MEDIAL ANGULATION. THIS WRITER CALLED ON CALL MALTC, NO ANSWERS, THIS WRITER LEFT DETAILED VOICEMAIL. LEADERSHIP MADE AWARE.A review of Resident #95's nurses note dated 3/4/25 at 7:38 AM read: ON CALL MALTC MADE AWARE AND MD [NAME] GAVE ORDER TO SEND TO ER. ORDER PLACED IN MAR. CHARGE NURSE AM SHIFT AND LEDERSHIP MADE AWARE.A review of Resident #95's nurses note dated 3/4/25 at 7:48 AM read: F/U Results Acute Fracture Left foot and ankle, Guardian JEWISH FAMILY SERVICES made aware.A review of Resident #95's nurses note dated 3/4/25 at 6:53 PM read: Resident was picked up by Fast Tract transportation to go to Sentara [NAME] Hospital for evaluation & treatment for fracture. JFS aware.A review of Resident #95's nurses note dated 3/5/25 at 3:15 AM read: This writer (Nurse name) called Sentara [NAME] Hospital. Per ER Nurse, Resident will be admitted Dx: B/L Tibial Fracture.A review of Resident #95's Radiology Results Report dated 3/4/25 at 12:37 AM read: Impression - There appears to be a fibular fracture.On 2/21/26 at 9:58 AM, an interview was conducted with Licensed Practical Nurse (LPN) #1. LPN #1 stated that the Certified Nursing Assistant (CNA) was in the resident's room performing ADL duties when the fall occurred. LPN #1 also stated that the CNA turned her back to rinse a washcloth, and the resident fell out of the bed onto the floor. LPN #1 further stated that the resident was dependent regarding care, and the CNA should not have left the bedside and allowed the patient to fall out of the bed. LPN #1 lastly stated that the CNA did not lower the bed while performing ADL care, and fall mats were not in use at the time.The Physician's Order Summary (POS) read, Devices: Floor Mats to the side of the bed while in bed for safety QS every shift for Safety r/t frequent falls with a start date of 4/11/2024.On 2/21/26 at 12:05 PM, an interview was conducted with the Minimum Data Set (MDS) Nurse. The MDS Nurse stated that due to Resident #95 being coded as dependent for Roll left and right: the ability to roll from lying on back to left and right side, and return to lying on back on the bed, the CNA needed to make sure the patient was in the middle of the bed and safe before turning her back. The MDS Nurse also stated that if a patient falls off the bed, it means the patient was not positioned safely. The MDS further stated that the CNA should have made sure she positioned Resident #95 safely before turning her back. On 2/21/26 at 12:40 PM, an interview was conducted with the Rehabilitation Manager. The Rehabilitation Manager stated that Resident #95 was totally dependent regarding ADL care and would not follow commands. The Rehabilitation Manager also stated that the CNA should have ensured the resident was in a safe position before turning her back while providing ADL Care.On 2/21/26 at 4:20 PM, an interview was conducted with the Director of Nursing (DON) and Administrator. The DON stated that when a resident is dependent, a CNA should provide total care. The DON also stated that the CNA turning her back to rinse the washcloth was a safety issue. A review of Post Fall Review documentation dated 2/25/2025 at 10:30 AM read: Description of Fall - Resident rolled from bed while aid was in the room with the patient providing ADL care.The facility's Fall Prevention and Management policy was presented on 2/22/26 at 10:17 AM by the Regional Nursing Consultant without an effective date. The policy read, Policy: It is the policy of this facility to provide resident-centered care that meets the psychological, physical, and emotional needs and concerns of the residents. Fall prevention and management is the process of identifying risk factors that can maximize the potential for falls, and also a process to manage a resident's care if a fall occurs. Fall Risk Assessment: Other factors should include the environment, medications, physical and mental diagnosis as well as the resident's current ADL status.On 2/22/26 at approximately 4:35 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Nursing Consultant. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on information obtained during the Infection Control task, the facility staff lacked documentation of all staff members' COVID-19 information. The findings included: On 2/21/26 at approximately 10:05 AM, the Infection Control information for the facility's staff was requested. The Director of Nursing (DON) stated at 4:38 PM that she was unable to locate COVID-19 information for all staff. There was no documentation that any staff had been provided with education regarding the benefits and potential risks associated with the COVID-19 vaccine, or that staff were offered the COVID-19 vaccine or information on obtaining it.On 2/22/26 at 4:40 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. An opportunity was offered to the facility's staff to present additional information, and the DON stated that they instruct staff to obtain the COVID-19 booster on their own because the facility does not offer it to the staff.

Based on staff interviews, facility document review, and clinical record review, it was determined that facility staff failed to report an allegation of abuse to the appropriate state agencies for two (2) of 45 residents in the survey sample, Resident #10 and Resident #42. The findings included: 1.The facility staff failed to report an allegation of abuse to the appropriate state agency. Resident #10 was originally admitted to the facility 11/27/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; Chronic Pain and Insomnia, unspecified. The quarterly, Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/25/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #10 cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals) the resident was coded as dependent with shower/bathe self, toileting hygiene, lower body dressing and putting on taking off footwear. Requiring partial moderate assistance with personal hygiene, requiring set-up or clean up assistance with oral hygiene and coded as independent with eating. 02/19/2026 1:41 pm., during the initial tour an interview was conducted with Resident #10 concerning her care and treatment. The resident said that she doesn't get changed for hours and have to lay in her wetness about 1 1/2 weeks ago. I'll call my son and say baby I'm wet. And he will call the nurse's station. Resident #10 also mention that the staff don't know how to talk to you right sometimes, but I talk rough back to them. On 2/21/26 the administrator was asked for any complaints, incidents or grievances involving Resident #10. A review of the Complaint/Grievance Report dated 2/05/26 read that a Certified Nursing Assistant (CNA) told her that She needs to get her ass washed when she refused to take a shower after 10:00 pm. The investigative finding read that the CNA involved in her care said that she didn't tell the resident to get her ass washed, the CNA said when she asked the resident to take her shower, she (resident) started yelling. The plan to resolve the complaint read the staff member was removed from Resident #10, the staff was counseled. The resolution read that staff members were educated and counseled and removed from her assignment. The document also read that the residents were satisfied and the investigation results and resolution steps were reported to the resident. On 2/22/26 an interview was conducted at 12:55 pm, with the Unit Manager, Licensed Practical Nurse (LPN) #2 concerning Resident #10. LPN #2 said according to the resident the CNA came in too late because it was after 10:00 pm because by then she was waiting to take her medication. According to LPN #2 the CNA approached the resident the next night concerning giving her a shower but said the resident started yelling and cursing at her. The LPN was asked if the CNA was assigned to resident the next night. LPN #2 said no, she wasn't assigned to the resident the next night due to the incident. LPN #2 said that she interviewed the staff and consulted Human Resources (HR) concerning what took place. LPN #2 said that HR recommended that the staff be suspended. She said she contacted the Director of Nursing (DON), who informed me to educate the staff. LPN #2 also mentions that the incident occurred on 2/03/26 during the 3-11 shift. LPN #2 said that she should have reassigned the CNA and that she did not conduct any interviews with other staff concerning the incident. On 2/22/26 at approximately 1:15 pm, an interview was conducted with CNA #4. CNA #4 said, The resident was on my assignment on 2/03/26 and had a Bowel Movement (BM), and I told her she was on my list for a shower when she told me to come back after her breathing treatment. I then said, I would have to shower her tomorrow, then she started fussing and cussing at me.On 2/22/26 at approximately 2:15 pm, a brief interview was conducted with Resident #10 concerning the incident with CNA #4. The resident said that she was supposed to get a shower on Tuesday night (night of incident 2/03/26) and the CNA came into her room saying that she would come back after dinner to give her a shower around 10:10 pm. The resident said, I was already given my medicine to help me sleep, and I was slightly sedated. I didn't want to fall or get hurt in the shower. So, I told her that I wasn't going to take a shower tonight. The CNA told me that I need to get up and wash my ass. I told her that she needed to wash her funky ass after she told me that. It usually takes two aides to shower me, but she was going to try to shower me herself. A review of the interviewer's statements was written on 2/05/26 by seven (7) staff members. All seven (7) staff wrote they didn't witness anything.The Policy: Abuse, Neglect and Exploitation dated 11/01/2020 and revised on 12/01/2022 read: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Verbal Abuse: Means the use of oral, written or gestured communication or sounds that willfully include disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Reporting/Response: The facility will have written procedures that include Reporting all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specific timeframes: a. Immediately, but not later than 2 hours after the allegation is made. The administrator will follow up with government agencies during business hours to confirm the initial report was received.On 2/22/26 at 2:20 pm, a brief interview was conducted with the administrator. The administrator said she didn't report the incident and that she and the DON were away when it occurred. On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. 2. The facility staff failed to ensure an allegation of missing property was reported timely to the administrative staff and state agencies. Resident #42 was originally admitted to the facility 12/16/25. The resident has never been discharged from the facility. The current diagnoses included: Muscle weakness and Type 2 Diabetes. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/23/25 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 12 out of a possible 15. This indicated Resident #42 cognitive abilities for daily decision making were intact. This indicated that Resident #42's cognitive abilities for daily decision making were moderately impaired. In sectionGG(Functional Abilities Goals), the resident was coded as requiring supervision or touching assistance with toileting, shower/bath self, upper body dressing, and lower body dressing, and coded as requiring set-up or clean-up assistance with eating. On 02/20/2026 at approximately 2:44 pm, during the initial tour, Resident #42 said that she reported to a nurse supervisor and other staff two weeks ago that she was missing two (2) debit cards, a driver's license, and an insurance card. The resident also mentioned that she had contacted her bank.02/20/2026 at approximately 3:49 pm, Licensed Practical Nurse #2, concerning the above allegation, said that she contacted supervisors from all shifts concerning the allegation, saying that none of the supervisors were aware of the allegations. LPN #2 said she spoke with the Social Worker, who is now filing a grievance with the resident regarding her allegation. On 02/20/2026 at approximately 3:58 pm., a brief interview was conducted with the DON and administrator. The administrator said that she has initiated a Facility Reported Incident (FRI). On 2/21/26, an interview was conducted with the Housekeeping (HK) concerning Resident #42. The HK staff said that over a week ago, while she was in the resident's room to pick up her laundry, the resident complained that she was missing her ID cards and her Medicaid card. She was informed to contact her family first, then the administration. The HK staff also mentioned that she told the resident that she couldn't report the incident. The HK stated, I helped her look for them, moved the bed, looked in laundry. I did tell one of the LPNs who works up front. I should have told my boss.The Policy: Abuse, Neglect and Exploitation dated 11/01/2020 and revised on 12/01/2022 read: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of Resident Property: means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of a resident's belongings or money without the resident's consent.Reporting/Response: The facility will have written procedures that include Reporting all alleged violations to the administrator, state agency, adult protective services, and to all other required agencies within specific timeframes: a. Immediately, but not later than 2 hours after the allegation is made. The administrator will follow up with government agencies during business hours to confirm the initial report was received.On 2/22/26 at 2:20 pm, a brief interview was conducted with the administrator. The administrator said that the incident should have been reported by staff once they were informed of the incident and a FRI should have been initiated.On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings.

Based on resident and staff interviews and a review of the clinical record, the facility staff failed to provide the necessary activities of daily living (ADLs) for 2 dependent residents (Resident #79 and Resident #10) of the 45 residents in the survey sample.The findings included: 1. Resident #79 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included old stroke with residual right-sided weakness, GI bleed, and COPD. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/12/2025, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #79's cognitive abilities for daily decision-making were intact. The resident had a care plan problem with a revision date of 6/08/2022, which stated that the resident has an ADL self-care performance deficit related to activity intolerance, confusion, fatigue, and CVA with right-sided hemiparesis. The goal had a revision date of 1/19/2026, and it stated that the resident will improve the current level of function in ADLs through the review date, 5/10/2026. Some of the interventions included TRANSFER: The resident requires Mechanical Lift (SIT-TO-STAND) with 2 staff assistance for transfers in/out of bed and 2 person assist for toileting. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Allow sufficient time for dressing and undressing. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self. An interview was conducted with Resident #79 on 2/19/26 at approximately 11:24 AM. Resident #79 stated that the night shift Certified Nursing Assistants (CNAs) give her a bed bath, dress her, and help her out of bed and into a wheelchair daily at 5:30 AM. Resident #79 stated that she is aware when she needs to toilet, but getting assistance in a timely manner is the problem. The resident also stated she wanted showers, not just bed baths. The resident stated that because she will not allow staff to put her on the shower bed, they say she refuses showers. The resident stated she requested use of the shower chair because if she showers in bed, her hair will get wet and revert from the styling she receives every two weeks. The resident stated she can sit on the shower chair, but the staff will not allow her. A review of Resident #79's shower schedule revealed that she is scheduled to shower on the 11:00 PM to 7:00 AM shift. The DON stated that only people who had no idea of the time of the day were to have showers on the 11:00 PM to 7:00 AM shift. The DON then revised her statement, saying the resident requested to be out of bed each morning between 5:00 AM and 6:00 AM, which is why she would receive her shower during the night shift. The DON further stated that the resident had never expressed a desire not to shower on the shower bed because it would make her hair wet. The DON was dismissive of the resident's goals for her ADL care, and she failed to consider development interventions she could implement to assist the resident in showering in the shower chair to prevent her hair from getting wet while still achieving the resident's desire for showers. The resident also stated that she must always wait for two CNAs because she is required to transfer using a Hoyer lift. The resident stated that often with her bowels, she has to push greatly to expel them because she has to wait so long for assistance after the urge, and with urination, she frequently urinates in the incontinence brief by the time the staff comes to render her care. The resident stated her goal is to eliminate normally, sitting on the commode, not intentionally in a brief, or lying in bed for a bowel movement. The resident also stated that she is not offered toileting services throughout the day, every 2-3 hours, as she is told by the licensed nursing staff is the expectation. The resident further said she does not receive incontinence care until after lunch daily. The resident reiterated that she does not receive care for her bowels or bladder from 5:30 AM until after lunch daily. The resident adamantly stated that when she activates the nurses' call light, the staff answers it, comes in to hear what care she needs, and then tells her, I have to get someone to help me. The resident said the staff does not return for hours, usually not until after lunch. The resident further stated that when the staff finally provides incontinence care after lunch, the incontinence brief is so heavy that it plops, making a loud noise when they drop it into the trash bag on the floor. Resident #79 stated she is strong enough to use the sit-to-stand lift, but facility staff said she must transfer using the Hoyer lift for her and staff's safety. On 2/19/26 at 11:24 AM, an interview was conducted with the Ombudsman. He stated that he frequently receives calls from Resident #79 regarding her basic care for incontinence, bathing, toileting, and repositioning to maintain her dignity. The Ombudsman stated that the resident is fearful of the Hoyer, and the facility staff stated that it is necessary because many staff have been injured while attempting to transfer the resident without a Hoyer, as she pulls against them. An interview was conducted with CNA #4 on 2/22/26 at 1:35 PM. CNA #4 stated that she checks on Resident #79 throughout the day but does not provide incontinence care until after lunch, close to 1:00 PM. CNA #4 stated Resident #79 is not toileted because she uses a Hoyer lift for transfers. CNA #4 said she had never seen a special Hoyer pad in the facility, which was designed for toileting and showers. On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and the facility's staff were given the opportunity to provide information they considered pertinent to the findings. The Administrator stated they had the special Hoyer pad in the facility for Resident #79 to use and documented interventions they had instituted to allow the resident to use the least-restrictive device for transfers, toileting, and showers, and to allow the resident the dignity she desired during transfers to obtain the services she desired. The facility staff failed to provide any documentation or interventions that they stated were offered to the resident. 2. Resident #10 was originally admitted to the facility 11/27/23 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included: Chronic Pain and Insomnia, unspecified. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/25/26, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #10's cognitive abilities for daily decision making were intact. In sectionGG(Functional Abilities Goals), the resident was coded as dependent with shower/bathe self, toileting hygiene, lower body dressing, and putting on and taking off footwear. Requiring partial moderate assistance with personal hygiene, requiring set-up or clean-up assistance with oral hygiene, and coded as independent with eating. The person-centered care plan, revised on 1/15/24, read that Resident #10 has an ADL self-care performance deficit r/t COPD, obesity. The Goal for the resident was that the resident would improve their current level of function in ADLs. The Interventions for the resident included: Encourage the resident to use the bell to call for assistance and discuss with the resident/family/POA any concerns related to loss of independence, decline in function. 02/19/26 1:41 pm., during the initial tour an interview was conducted with Resident #10 concerning her care and treatment. The resident said that she doesn't get changed for hours and has to lie in her wetness, and it has been happening for about 1 1/2 weeks. We don't get changed, it takes 30 minutes to an hour before they check on me. I'll call my son and say, Baby, I'm wet. And he will call the nurse's station. On 2/22/26 at approximately 2:15 pm., a brief interview was conducted with Resident #10. Resident #10 said, I stayed wet from 11:00 pm last night until this morning after 7:00 am. On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and the facility's staff were given the opportunity to provide information they considered pertinent to the findings.

Based on observation, staff interviews, clinical record review, and review of facility documents, the facility staff failed to provide services to maintain hearing abilities for 1 of 45 residents (Resident #14), in the survey sample.The findings included: The facility staff failed to ensure that Resident #14 have access to and receive proper treatment and assistive devices to maintain hearing abilities.Resident #14 was no longer a resident of the facility; therefore, a closed record review was conducted. Resident #14 was admitted to the facility on [DATE] after a hospital stay. The resident's diagnoses included Parkinson's disease without dyskinesia, major depressive disorder, and muscle weakness. Resident #14 was coded as rarely/never understood so there was no Brief Interview for Mental Status (BIMS) completed.During an observation tour on 2/19/26 at 1:50 PM it was observed that Resident #14 was not wearing hearing aids. On 2/19/26 at 1:55 PM an interview was conducted with Registered Nurse (RN) #2. RN #2 stated that she cannot find the hearing aids for Resident #14 and she believes they have been lost. On 2/20/26 at 5:25 PM an interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated that she and the DON did not know that Resident #14 was missing her hearing aids until 2/19/26 when they were informed by the Unit Manager that Resident #14 did not have them. On 2/21/26 at 9:15AM the Administrator stated that she spoke with the Resident #14's daughter the prior night and discussed that the hearing aids were lost and the plan is for the facility to set up an Audiologist appointment. On 2/21/26 at 1:00 PM an interview was conducted with Resident # 14's Daughter. Resident # 14's Daughter stated that in 2018 she purchased Resident #14 a new pair of hearing aids and in 2021 the facility Social Worker informed her that the facility staff lost the hearing aids. Resident # 14's Daughter also stated that in January 2023 she purchased another pair of hearing aids for Resident #14 that cost over $5000.00. Resident # 14's Daughter further stated that in August of 2024 the facility lost the hearing aids again. Resident # 14's Daughter lastly stated that she has spoken with the facilities Director of Social Worker about this many times and was told that the facility is not responsible for her Mother's hearing aids. On 2/21/26 at 2:50 PM an interview was conducted with the Director of Social Services. The Director of Social Services stated that on 8/7/2025 during a care plan meeting, Resident #14's daughter informed the staff that Resident #14's hearing aids are missing. The Director of Social Services also stated that the facility has not assisted the resident or resident representative in locating resources, making appointments, or setting up transportation regarding replacing the lost hearing aids. The Care Plan with a created on date of 12/4/20 read that resident has a communication problem r/t Head Injury, Weak voice, HOH wears hearing aids, decreased visual acuity, increasing confusion. The goal is the resident will be able to make basic needs known on a daily basis through the review date. The intervention for Resident #14 was ensure hearing aid to both ears are in place.The facility's Hearing and Vision policy with a date reviewed/revised of 12/1/2022 reads, Policy: It is the policy of this facility to ensure that residents have access to and receive proper treatment and assistive devices to maintain vision and hearing abilities. Policy Explanation and Compliance Guidelines: 3. The social worker /social service designee is responsible for assisting residents, and their families, in locating and utilizing any available resources(e.g. Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of the vision and hearing services the resident needs. 4. Once vision or hearing services have been identified, the social worker/social service designee will assist the resident by making appointments and arranging for transportation.On 2/22/26 at approximately 4:35 PM, a final interview was conducted with the Administrator, Director of Nursing, and Regional Nursing Consultant. An opportunity was offered to the facility's staff to present additional information. They had no further comments and voiced no concerns regarding the above information.

Based on resident and staff interviews and a review of the clinical record, the facility staff failed to provide appropriate treatment and services to assist Resident #79 to achieve as much bowel and bladder control as possible, for 1 of 45 in the survey sample. The findings included: Resident #79 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included old stroke with residual right-sided weakness, GI bleed, and COPD. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/12/2025, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #79's cognitive abilities for daily decision-making were intact.The resident had a care plan problem with a revision date of 6/08/2022, which stated that the resident has an ADL self-care performance deficit related to activity intolerance, confusion, fatigue, and CVA with right-sided hemiparesis. The goal had a revision date of 1/19/2026, and it stated that the resident will improve the current level of function in ADLs through the review date, 5/10/2026. Some of the interventions included TRANSFER: The resident requires Mechanical Lift (SIT-TO-STAND) with 2 staff assistance for transfers in/out of bed and 2 person assist for toileting. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Allow sufficient time for dressing and undressing. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.An interview was conducted with Resident #79 on 2/19/26 at approximately 11:24 AM. Resident #79 stated that the night shift Certified Nursing Assistants (CNAs) give her a bed bath, dress her, and help her out of bed and into a wheelchair daily at 5:30 AM. Resident #79 stated that she is aware when she needs to toilet, but getting assistance in a timely manner is the problem. She stated that she must always wait for two CNAs because she is required to transfer using a Hoyer lift. The resident stated that often with her bowels, she has to push greatly to expel them because she has to wait so long for assistance after the urge, and with urination, she frequently urinates in the incontinence brief by the time the staff comes to render her care. The resident stated her goal is to eliminate normally, sitting on the commode, not intentionally in a brief, or lying in bed for a bowel movement. The resident also stated that she is not offered toileting services throughout the day, every 2-3 hours, as she is told by the licensed nursing staff is the expectation. The resident further said she does not receive incontinence care until after lunch daily. The resident reiterated that she does not receive care for her bowels or bladder from 5:30 AM until after lunch daily.The resident adamantly stated that when she activates the nurses' call light, the staff answers it, comes in to hear what care she needs, and then tells her, I have to get someone to help me. The resident said the staff does not return for hours, usually not until after lunch. The resident further stated that when the staff finally provides incontinence care after lunch, the incontinence brief is so heavy that it plops, making a loud noise when they drop it into the trash bag on the floor. Resident #79 stated she is strong enough to use the sit-to-stand lift, but facility staff said she must transfer using the Hoyer lift for her and staff's safety. On 2/19/26 at 11:24 AM, an interview was conducted with the Ombudsman. He stated that he frequently receives calls from Resident #79 regarding her basic care for incontinence, bathing, toileting, and repositioning to maintain her dignity. The Ombudsman stated that the resident is fearful of the Hoyer, and the facility staff stated that it is necessary because many staff have been injured while attempting to transfer the resident without a Hoyer, as she pulls against them. Has psych services on board. An interview was conducted with CNA #4 on 2/22/26 at 1:35 PM. CNA #4 stated that she checks on Resident #79 throughout the day but does not provide incontinence care until after lunch, close to 1:00 PM. CNA #4 stated Resident #79 is not toileted because she uses a Hoyer lift for transfers. CNA #4 said she had never seen a special Hoyer pad in the facility, which was designed for toileting and showers.On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. The Administrator stated they had the special Hoyer pad in the facility for Resident #79 to use, and documented interventions they had instituted to allow the resident to use the least-restrictive device for transfers, toileting, and showers, and to allow the resident the dignity she desired during transfers. The facility staff failed to provide any documentation or interventions that they stated were offered to the resident.

Based on resident and staff interviews and a review of facility documents, the facility staff failed to ensure that the binding arbitration agreement was clearly explained to three (3) of 45 residents (Residents #97, 3, and 79) in the survey sample. The findings included: 1. The facility staff failed to ensure that the binding arbitration agreement was clearly explained to Resident #97. Resident #97 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included stroke with left hemiplegia, chronic back pain, and diarrhea. The resident had not been admitted to the facility long enough for the Minimum Data Set (MDS) to be completed; therefore, the following information was obtained from the Admission/readmission Screening dated 2/15/26. The screening revealed the resident was alert and oriented to person, place, and situation, and was verbally appropriate.An interview was conducted with Resident #97 on 2/22/26 at approximately 1:37 PM. The focus of the interview was the arbitration agreement, which the resident signed during the admission process. The resident stated he didn't recall signing a document that would deprive him of the right to a trial by a judge or jury in the event of a dispute between him and/or his family and the facility. The resident further stated that he believed the facility staff were good people, so he was not too concerned about possibly needing to activate the litigation process. An interview was conducted with the Admissions Director on 2/22/26 at approximately 3:58 PM. The Admissions Director stated that when reviewing the admission documents, she reads the arbitration agreement to the resident and/or the person completing the admission documents. The Admissions Director did not state that the resident said that he understood what an arbitration agreement was or that the resident was told he had the right to decline the agreement by simply crossing out the document, and a copy was not left with the resident for further review to make an informed decision prior to the allowed 30 days to rescind the agreement. On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. The Regional Nurse Consultant stated that the document was legal and binding because the resident signed it. 2. The facility staff failed to explain the binding arbitration agreement to Resident #3 in a manner that the resident understood.Resident #3 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included Chronic pain in the right foot, Bipolar I disorder, and COPD. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 1/31/26, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #3's cognitive abilities for daily decision-making were intact.An interview was conducted with the resident on 2/22/26 at 9:35 AM. During the interview, the resident stated that she was not knowledgeable of the binding arbitration agreement and how it affected her. This information was conveyed to the Admissions Director and the Director of Social Services. The Director of Social Services stated on 2/22/26 at approximately 2:45 PM that she and the Admissions Director interviewed Resident #3 regarding the binding arbitration agreement. The Director of Social Services further stated that the resident was unfamiliar with the agreement, and it was explained to her in a manner she understood. An interview was conducted with the Admissions Director on 2/22/26 at approximately 3:58 PM. The Admissions Director stated that when reviewing the admission documents, she reads the arbitration agreement to the resident and/or the person completing the admission documents. The current Admissions Director was not the person who witnessed Resident #3's signature on 9/8/2023.There was no documentation that stated that the resident said she understood what an arbitration agreement was or that the resident was told she had the right to decline the agreement by simply crossing out the document, and a copy was not left with the resident for further review to make an informed decision prior to the allowed 30 days to rescind the agreement. On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. The Regional Nurse Consultant stated that the document was legal and binding because the resident signed it.3. The facility staff failed to ensure that Resident #79 understood the terms of the binding arbitration agreement. Resident #79 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included old stroke with residual right-sided weakness, GI bleed, and COPD. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/12/2025, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #79's cognitive abilities for daily decision-making were intact.An interview was conducted with the resident on 2/22/26 at 9:55 AM. During the interview, the resident stated that she was unaware of the binding arbitration agreement she had signed three years ago. This information was conveyed to the Admissions Director and the Director of Social Services. The Director of Social Services stated on 2/22/26 at approximately 2:45 PM that she and the Admissions Director interviewed Resident #79 regarding the binding arbitration agreement. The Director of Social Services further stated that the resident was unfamiliar with the agreement, and it was explained to her in a manner she understood. An interview was conducted with the Admissions Director on 2/22/26 at approximately 3:58 PM. The Admissions Director stated that when reviewing the admission documents, she reads the arbitration agreement to the resident and/or the person completing the admission documents. The current Admissions Director was not the person who witnessed Resident #79's signature on 2/1/2023.There was no documentation that stated that the resident said she understood what an arbitration agreement was or that the resident was told she had the right to decline the agreement by simply crossing out the document, and a copy was not left with the resident for further review to make an informed decision prior to the allowed 30 days to rescind the agreement. On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. The Regional Nurse Consultant stated that the document was legal and binding because the resident signed it.

Based on observations and a review of resident dietary tickets, the facility staff failed to serve portions of the planned menu for two (2) of 45 residents (Resident #32 and Resident #64) in the survey sample. the findings included: 1.The facility staff failed to ensure Resident #32's breakfast included boiled eggs and milk, instead of scrambled eggs and milk. Resident #32 was originally admitted to the facility 4/07/25 after an acute care hospital stay. The current diagnoses included: Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Left Non-Dominant Side and Contracture of Muscle, Left upper arm. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/17/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 8 out of a possible 15. This indicated that Resident #32's cognitive abilities for daily decision making were moderately impaired. In sectionG(Physical functioning), the resident was coded as requiring set up or clean up assistance with eating, dependent with bed mobility, transfers, locomotion, dressing, toileting, oral hygiene, shower/bathe self, personal hygiene, and bathing.On 2/21/26 at approximately 9:05 am, an observation of the resident's tray was conducted at breakfast. The residents' meal tray consisted of scrambled eggs, sausage, an English muffin, coffee, and Orange Juice. The meal ticket read: Hard Boiled Eggs, Sausage Patty, English Muffin, milk, and coffee.On 2/21/26 at approximately 6:35 pm., during the end-of-day meeting, the above concern was shared with the Administrator, DON, and the Regional Nurse Consultant. An opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. On 2/22/26 at approximately 12:25 pm., an interview was conducted with Certified Nurse's Aide (CNA) #1. CNA #1 said that the resident does better with finger foods. On 02/22/2026 at approximately 2:39 pm., an interview was conducted with the Dietary Manager (DM) concerning the residents' breakfast. The DM said that the nursing staff should have communicated their concern to him and he would have prepared the resident a boiled egg and educated the dietary staff as well. 2. The facility staff failed to ensure Resident #64's breakfast included boiled eggs and Bacon. Resident #64 was originally admitted to the facility on [DATE] after an acute care hospital stay. The current diagnoses included: Type 2 Diabetes Mellitus and Morbid Obesity. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 1/15/26 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated that Resident #64's cognitive abilities for daily decision making were intact. oIn sectionG(Physical functioning), the resident was coded as being independent with eating, toileting, and hygiene, requiring set-up or clean-up assistance with oral hygiene and personal hygiene. Requires supervision or touching assistance with shower/bathe self.On 2/21/26 at approximately 9:00 am., an observation of the resident's tray was conducted at breakfast. The residents' meal tray consisted of scrambled eggs, sausage, an English muffin, oatmeal, apple juice, and hot chocolate.The meal ticket read: Hard Boiled Eggs, Mechanical sausage patty with cream gravy, Bacon x2, English Muffin, Apple Juice, hot chocolate, and Ensure Shake (Vanilla). The resident said this is how the meals come sometimes, but she really wanted bacon and boiled eggs.On 2/21/26 at approximately 6:35 pm., during the end-of-day meeting, the above concern was shared with the Administrator, DON, and the Regional Nurse Consultant. An opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. On 2/22/26 at approximately 12:25 pm., an interview was conducted with Certified Nurse's Aide (CNA) #1. CNA #1 said that, normally, she would contact the kitchen to see if they have what the resident had asked for.On 02/22/2026 at approximately 2:39 pm., an interview was conducted with the Dietary Manager (DM) concerning the residents' breakfast. The DM said that the nursing staff should have communicated their concern to him, and he would have prepared a boiled egg for the resident and educated the dietary staff as well.

Based on resident and staff interviews and a review of the clinical record, the facility staff failed to review and revise the person-centered care plan as the resident's condition changed for 1 of 45 residents (Resident #79) in the survey sampleThe findings included: Resident #79 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' current diagnoses included old stroke with residual right-sided weakness, GI bleed, and COPD. The significant change Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/12/2025, was coded that the resident completed the Brief Interview for Mental Status (BIMS) and scored 15 out of 15. This indicated that Resident #79's cognitive abilities for daily decision-making were intact.The resident had a care plan problem with a revision date of 6/08/2022, which stated that the resident has an ADL self-care performance deficit related to activity intolerance, confusion, fatigue, and CVA with right-sided hemiparesis. The goal had a revision date of 1/19/2026, and it stated that the resident will improve the current level of function in ADLs through the review date, 5/10/2026. Some of the interventions included TRANSFER: The resident requires Mechanical Lift (SIT-TO-STAND) with 2 staff assistance for transfers in/out of bed and 2 person assist for toileting. BATHING/SHOWERING: Check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. DRESSING: Allow sufficient time for dressing and undressing. DRESSING: Assist the resident to choose simple comfortable clothing that enhances the resident's ability to dress self.An interview was conducted with CNA #4 on 2/22/26 at 1:35 PM. CNA #4 stated that she checks on Resident #79 throughout the day but does not provide incontinence care until after lunch, close to 1:00 PM. CNA #4 stated Resident #79 is not toileted because she uses a Hoyer lift for transfers. CNA #4 said she had never seen a special Hoyer pad in the facility, which was designed for toileting and showers.On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and the facility's staff were given the opportunity to provide information they considered pertinent to the findings. The Administrator stated they received a message from the hospital that the resident is no longer allowed to use the sit-to-stand lift. The Administrator stated they had the special Hoyer pad in the facility for Resident #79 to use, and they had documented interventions they had instituted to allow the resident to use the least-restrictive device for transfers, toileting, and showers, and to allow the resident the dignity she desired during transfers to obtain the services she desired. The facility staff failed to provide any documentation or interventions that they stated were offered to the resident, and they failed to revise the care plan when they determined the resident was safer using the Hoyer lift.

Based on observations, resident and staff interviews, and a review of the clinical records, the facility staff failed to accurately code the Minimum Data Set (MDS) assessment for 1 of 45 residents (Resident #96) a closed record resident in the survey sample. Resident #96 was initially admitted to the facility on [DATE] after an acute care hospital stay. The residents' diagnoses included non-pressured chronic ulcer of other part of left foot. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/28/25 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). The staff interview was coded for long and short term memory problems as well as severely impaired for daily decision making. Section M coded resident as having not having a pressure ulcer/injury, scar over a bony prominence.The modified Section M (Skin assessments) coded the resident as having a pressure ulcer/injury, scar over a bony prominence. On 2/21/26 at approximately 12:00 pm, an interview was conducted with the Minimum Data Set Coordinator (MDSC). Involving the above concern. The MDSC agreed that the above assessment had been coded inaccurately and will modify the assessment.On 2/21/26 at approximately 6:35 pm., End of Day meeting was conducted with the DON, the administrator and with the Regional Clinical Nurse Consultant. An opportunity was offered to the facility's staff to provide additional information.

Based on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to notify the resident's family representative (daughter) of a change in condition for one (1) of 45 residents (Resident #8), a closed record resident in the survey sample. The findings include: Resident #8 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included: Hemiplegia and Hemiparesis following Cerebral Infarction affecting the right dominant side and Cognitive Communication Deficit. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/29/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated that Resident #8's cognitive abilities for daily decision making were severely intact. In sectionG(Physical functioning), the resident was coded as requiring partial/moderate assistance with oral hygiene and personal hygiene. Coded as dependent with toileting hygiene, shower/bathe self, and taking on and putting off footwear. Coded as requiring substantial/maximal assistance with upper body dressing and lower body dressing. Requires assistance with eating set-up or clean-up. The personal-centered care plan dated 7/10/25 read that the resident has an ADL self-care performance deficit r/t Activity Intolerance, Fatigue, Impaired balance, and Tremors. The Goal for Resident #8 will be to maintain the current level of function in bed mobility, transfer, eating, and dressing. The intervention included the resident being totally dependent on 2 staff for transferring. On 2/20/26 at approximately 9:05 am, an interview was conducted with an Adult Protective Services worker (APS). The APS worker said they didn't validate these concerns of abuse due to the client being in the hospital and not returned to the facility. One concern in question was that the client had an incident during therapy in which she appeared to overexert herself, so the therapist requested the facility to put her back in bed because she became unresponsive to commands during therapy. After putting her in bed, no one came back to check on her. The nurse had been made aware that she was back in her bed, but it was said that no one had come. The Fire Department came and found the client was in Atrial Fibrillation (afib). The Medication Administration Record (MAR) revealed the resident received Tetrabenazine Oral Tablet 25 MG (Tetrabenazine). Give 1 tablet by mouth three times a day for tremors. Start Date: 11/26/2025 9:00 pm. A review of the February 2026 MAR revealed the resident missed two (2) doses of the above medications that were ordered to help her with her tremors on 2/08/26 and 2/09/26. The Change in Condition (CIC) dated 1/09/26 at 2:22 pm., revealed at the time of evaluation resident vital signs were Blood Pressure: BP 128/83, Pulse: P 103, (Regular), Respiration 16, Temp: T 98.5 Route: Forehead, Pulse Oximetry: O2 93.0 % Room Air and weight 101.2 lb obtained on 1/01/26 using the mechanical lift scale.0 A timeline of events that occurred on 1/09/26 leading up to Resident #8's change in condition, resulting in hospitalization, was as follows:At 8:20 am, the resident is waiting in the lobby for transportation to an appointment.At 9:00 am, the Medical Records staff called the insurance company to report a transport no-show.At 11:30 am, a Certified Occupational Therapy Assistant (COTA) saw the resident sitting in the day room. Awake but felt hot. Resident taken to the dining room. The COTA progress note read, Patient seen for ADL/ROM; however, the patient was sweating, non-verbal, with increased tremors, and the nurse was made aware. Patient dependent on transfer back to bed.At 12:00 pm, Put resident to bed with aide assistance. Resident awake but not talking. COTA, showed Licensed Practical Nurse (LPN) #5 resident's hand and arms are discolored.At 12:58 pm, Physical Therapy session with Physical Therapist (PT) #4, Resident not attempting to initiate tasks in therapy. pt. alert but not verbally responding, unable to complete task.At 1:40 pm, the resident's daughter-in-law signed in as a visitor according to the facility's sign-in sheet.At 2:00 pm, the clinician was notified.At 2:15 pm, the paramedics arrived. The following interviews were conducted:On 2/19/26 at approximately 7:35 pm, an interview was conducted with LPN #5. LPN #5 said, The Certified Nursing Assistant said that the resident's daughter (meant daughter-in-law) wanted the resident's vital signs checked. Her vital signs were due to be checked at 2:00 pm. The resident's daughter (daughter-in-law) started screaming, saying you need to check my mom's vital signs. I called the unit manager and the Director of Nursing (DON). Her heart was tachycardic; otherwise, vital signs were normal. LPN #2 also mentioned that when she went into the resident's room, the resident was talking until her daughter-in-law came back into the room. LPN #2 then said that due to the resident's altered mental status and unresponsiveness, the doctor said to send her to the Emergency Room. LPN #5 further said that the resident was talking and drinking soda and that she was not aware of any incidents occurring in therapy. LPN #5 stated, They took her to the dining room after therapy. She didn't want to stay, so they took her to her bedroom. No one said she was unresponsive in therapy and got overexerted. I would have informed the doctor. Sometimes the therapist may inform you of things. The CNA no longer works here. Most of the time, therapy will push the resident into the dining room. She was a Hoyer Lift (full mechanical lift), and I don't know who the second CNA was. I was put on hold for a brief moment, then I got off the phone with 911. On 2/20/26 at approximately 12:25 pm, an interview was conducted with the COTA staff. The COTA staff said that she had the resident close to lunch time, and she was in the day room. It was hot, and she took off the resident's sweatshirt. She stated that she informed a nurse in the dining room that the resident wasn't verbalizing as much as she usually was, but able to make her needs known, as she has Parkinson's, and mostly spoke very few words. She said the resident was staring more than usual, not making eye contact, and seemed to be daydreaming, unable to focus or answer anything. The COTA said, I requested they put her in bed and helped them put her in bed. The resident was a dependent transfer; she was sitting in her wheelchair. We performed a wheelchair-to-bed transfer; the resident couldn't assist. The resident had Physical therapy earlier that morning. On 2/20/26 at approximately 1:00 pm., an interview was conducted with the Physical Therapist (PT). The PT said that the resident was seen briefly on 1/09/26 early in the morning. PT said, The resident was already in the lobby waiting for transportation to arrive to take her to her doctor's appointment. I asked the CNA to take the resident to the gym to complete paperwork because today was the resident's last day of therapy. After we got to the gym, I asked the resident to stand, but she only looked at me. The resident reached for the parallel bars, and she sat back down. She didn't follow any commands, just stared at me. The COTA had told me that the resident had had episodes like this in the past. On 2/20/26 at approximately 1:50 pm, an interview was conducted with the Medical Records Coordinator (MRC). The MRC said that he had set up an appointment for the resident to attend a doctor's appointment on 1/09/26 at 9:00 am. The MRC said transportation was supposed to pick up the resident at 8:20 am. The insurance company personnel said that the resident's transportation was canceled incorrectly. On 2/21/26 at approximately 5:35 pm, an interview was conducted with LPN #2. LPN #2 said that while in the morning meeting, LPN #5 said that as she entered the resident's room, her daughter was upset, saying her mother doesn't look good and that she's sweating. LPN #5 also said that the DON and LPN #2 were at the bedside giving the resident tea and ice cream. LPN #5 also mentioned that she called the Physician's Assistant, who advised calling 911. LPN #5 said that she was informed that the resident was sweating in the gym. On 2/22/26 at approximately 9:30 am, an interview was conducted with the resident's daughter-in-law. She said that she arrived at the facility around 1:40 pm, entered the resident's room, and found her loved one not at her normal baseline, staring and looking sleepy. The CNA walked in and said she's been like this since noon. They called the paramedics and said she didn't talk to them. Her Blood Pressure was elevated; she was in a fib. The staff informed the paramedics that the resident had been riding the bike in PT and got too hot. We didn't receive a call from the facility before I came in at 1:40 pm. So, from 12 noon to 1:40 pm, no one checked on her. The resident didn't start talking until 1/10/26 after being hospitalized . According to the Weather Forecast for January 9th, 2026, in Virginia Beach, Virginia, the temperature was as follows: morning was 46 , Day was 57 , and evening was 63 . https://world-weather.info/forecast/usa/virginia_beach/january-2026/ On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings. The administrator said that the temperature was very hot on the day the resident felt hot. The DON said, They adjusted the resident's medications a few days ago due to anxiety. The resident's daughter started yelling, and the resident stopped speaking. She didn't become unresponsive. The resident was admitted to the facility in atrial fibrillation.

Based on observation, family interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure two infected advanced staged wounds on the Left ankle and Left Ischium were treated with antibiotics timely for 1 of 45 residents (Resident #71), in the survey sample. Resident #71 was originally admitted to the facility on [DATE] and readmitted on [DATE] after an acute care hospital stay. The resident has never been discharged from the facility. The current diagnoses included: Pressure ulcer of left heel, Pressure ulcer of left Ischium/buttock unstageable, and Muscle weakness. The quarterly Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 11/29/25, coded the resident as having completed the Brief Interview for Mental Status (BIMS) and scoring 2 out of a possible 15. This indicated that Resident #71's cognitive abilities for daily decision making were severely impaired. In section M (Skin Conditions) the resident was coded as being at risk for pressure ulcer/injuries.The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 2/20/26. In Section M (Skin Conditions), the resident was coded as having 1 unstageable pressure ulcer and 1 unstageable deep tissue injury.a. LEFT BUTTOCK PRESSURE ULCER: The person-centered care plan dated 2/05/26 read that the resident had a pressure ulcer on the left buttock r/t incontinence and decreased mobility. The Goal for the resident: Pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions were: Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage, and Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. A review of the Treatment Administration Record (TAR) revealed on 2/05/26 at 7:00 am., Santyl Ointment 250 UNIT/GM (Collagenase) Apply to per additional directions topically every day shift for wound care Clean with DWC, pat dry, apply Santyl to Lt. Buttock and cover with clean dressing until healed and on 2/06/26 at 7:00 am., Santyl Ointment 250 UNIT/GM (Collagenase) Apply to left buttock topically every day shift for wound care Apply Santyl topically every dayshift for wound care, Cleanse L buttock with DWC/NS, pat dry, apply Santyl, dry gauze, and cover with foam dressing until healed.Braden Scale Score: 16.0 11/30/25. SENSORY PERCEPTION: Slightly limited. MOISTURE: Rarely Moist. ACTIVITY: Chairfast. MOBILITY: slightly limited. NUTRITION: Adequate. FRICTION & SHEAR: Problem. SCORING 16.A review of the January 2026 Physician's Order Summary (POS) revealed that the resident had orders to receive a Therapeutic Exchange Device (air mattress) q shift for wound care/prevention/to start 1/23/26 at 11:00 pm.A review of the February Physician's Order Summary revealed the following: Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for infection for 7 Days Verbal Active 02/21/2026.Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for Wound infection for 7 Days Verbal Active 02/21/2026.Wound timeline-left buttock:10/30/25 -A review of skin assessments revealed redness at the coccyx with treatment in place.A review of Nursing progress notes:02/21/26 at 2:53 pm, read Resident received new order for doxycycline 100 mg x 7 days, Responsible Party (RP) notified, resident also had an order.2/14/26 3:20 am, Resident's buttocks dressing changed w/some drainage noted, foul smell and redness surrounding the pressure/Santyl get applied, covered with foam dressing, re-positioned 2x/pillow supported back. Resident vital signs Temperature 97.7 and 02-97%. Endorse to the next on coming shift nurse. 2/14/2026 at 4:01 pm., Treatment provided to left buttock and heel as ordered. Responsible Party (RP) into visit this shift. Will advise oncoming nurse.2/21/26 at 8:29 pm., nurse received verbal order from hospice nurse and hospice Medical Doctor (MD) for doxycycline 100 mg x 7 days for L buttock wound infection, RP notified by hospice nurse, husband was present during visit, resident also received order PRN for morphine and Lorazepam as needed.On 2/23/26 A review of a wound assessment revealed the first evaluation of a left buttock wound by wound care provider who identified the wound on 2/23/26 to the left buttock as unstageable covered with 100% Eschar, heavy exudate, seropurulent and malodorous measuring 7.00 cm, Width: 6.00 cm, Depth: 1.00 cm. The treatment consisted of Daily, and as needed (PRN) wound care: Cleanse with 0.125% Dakins solution Calcium Alginate with Silver silicone bordered super absorb. On 2/18/26 at approximately 7:14 pm., during the initial tour, the resident was observed lying in a supine position asleep in her bed.On 2/20/26 at approximately 2:30 pm., a wound observation was conducted of the resident's left buttock with Licensed Practical Nurse (LPN) #1. The wound was malodorous and appeared to be necrotic; no drainage was observed. LPN #1 said the wound remained unchanged. LPN #1 was asked how long the resident's wound has been malodorous. LPN #1 reported that, in the last few wound care visits, the wound had an odor. LPN #1 also said there's no place to document that the resident's wound has an odor.On 02/20/26 at approximately 3:25 pm., a brief interview was conducted with the resident's spouse concerning the resident's wound. The resident's spouse said that he asked the staff if they could keep the resident in bed until lunchtime daily. The resident's spouse also said that the resident will be assigned to hospice services today.2/05/26 New Unstageable- Resident has non-stageable pressure ulcer (L buttocks, 3.5cm x 2cm. New order for treatment- Santyl gel collagenase covered w/ foam dressing. - Dressing done.A review of a hospice note dated 2/22/26 at 9:53 am, read received call that patient has a fever of 101 and requesting re-assessment of left buttock. Temperature 99.4, 94/52, pulse 90. Left buttock wound 7 cm x 7.5 cm wound bed. 100% necrotic peri-wound erythema, warm to touch with foul odor. Treatment: Cleanse with Dakins solution, Santyl to wound bed, covered with dry dressing, and Telfa island dressing. b. LEFT HEEL PRESSURE ULCER: The person-centered care plan revised on 2/19/26 read that resident has a left heel pressure ulcer. The Goal: Pressure ulcer will show signs of healing and remain free from infection by/through review date. The interventions were: Teach resident/family the importance of changing positions for prevention of pressure ulcers. Encourage small frequent position changes and assess/record/monitor wound healing weekly Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines.A review of a Physician Assistant's note dated 2/05/26 at 8:00 am read, Resident is seen today at the request of nursing for evaluation of a progression of her left buttock wound. The wound was recently noted to be stage I and is now unstageable. She also has a similar wound on her heel. Nursing has requested that we speak with the family about advance care planning, and a discussion was completed with her husband/RP today. The provider explained hospice-qualifying criteria to him, including her functional decline, recurrent infections, wound progression, and multiple comorbidities. RP agreed that hospice would be a good idea and is willing to meet with hospice representatives.Wound timeline-left heel:12/16/25 at 6:28 am, Resident's (L) heel was observed w/ pressure sore/injury. Bluish discoloration/. Cleaned and dressed w/ gauze covered (applied w/ bacitracin ointment). N/P made aware thru communication log book. Endorse to the next on coming shift Nurse.1/01/26 at 7:21 am, Left Heel, worsened wound per nursing progress note. LPN Charge Nurse notified this writer r/t existing wound to Left Heel possibly worsen. Request placed in MD Book for possible wound consult. Area cleansed with Bacitracin and covered with Dry dressing on this shift. This writer called Emergency Contact, RP, no answer. This writer left detailed voicemail. On Call made aware.1/14/26 Unspecified open wound, left foot, initial encounter- Patient presents with worsening left foot wound with evidence of cellulitis. Referred to wound care for specialized evaluation and management. Ordered x-ray of left foot to assess for underlying bone involvement on 1/2/2026, which showed moderate arthritic changes without acute fracture and no evidence of osteomyelitis. Will continue to monitor wound healing progress.2/4/26 4:10 pm, New treatment to L heel: Betadine to 4x4 gauze and wrap with kerlix daily every day shift for DTI. DO NOT PUT BORDERED DRESSING ON THE WOUND. Unable to complete this shift.2/05/26 Non-pressure chronic ulcer of other part of left foot with fat layer exposed *: Patient continues to have chronic ulcer on left heel with fat layer exposed. X-ray of left foot on 01/02/2026 showed moderate arthritic changes without acute fracture and no evidence of osteomyelitis. Wound care consultation was initiated on 01/02/2026 for specialized assessment and treatment recommendations. Currently applying Santyl ointment for debridement as documented in active medications started 02/04/26. Patient is under comfort care measures per established DNR status with specific directives including no labs and no hospitalizations. Will continue topical wound management and monitor for signs of infection or further deterioration. Zinc supplementation started 01/26/2026 to support wound healing.2/14/26 at 4:01 pm, a review of a nursing progress note read: Treatment provided to left buttock and heel as ordered. Husband is in to visit this shift. Will advise oncoming nurse. A review of a skin and wound date of service note on 2/16/2026 at 3:55 pm., revealed the first evaluation of existing wound by new wound care team. Wound: 1 Location: Left heel, Pressure Ulcer/Injury Stage/Severity: Unstageable Size: 3.9 cm x 6.5 cm x 0 cm. Calculated area is 25.35 sq cm.PROCEDURES: A sharp debridement was not performed today due to this is the first evaluation of the patient and further plan for debridement.On 2/20/26 at approximately 2:30 pm., a wound observation was conducted of the resident's left heel with Licensed Practical Nurse (LPN) #1. The wound was malodorous as LPN #1 removed the resident's dressing that appeared to have a small to moderate amount of drainage present on the resident's pillow, where her left heel was resting, and also had serosanguinous drainage on it. The wound on the left heel appeared to be necrotic/black with a tinge of creamy/yellow tissue on the wound. LPN #1 said the wound remained unchanged. LPN #1 was asked how long the resident's wound has been malodorous. LPN #1 reported that, in the last few wound care visits, the wound had an odor. LPN #1 also said there's no place to document that the resident's wound has an odor. On 02/20/26 at approximately 3:25 pm, a brief interview was conducted with the resident's spouse concerning the resident's wound. The resident's spouse said he asked the staff to keep the resident in bed until lunchtime daily. The resident's spouse also said that the resident will be assigned to hospice services today.According to the nursing progress notes, the hospice nurse assessed only the buttocks, not the left heel, on 2/21/26 at 8:29 pm.A review of nursing progress notes revealed on 2/22/26 at 10:45 am, the hospice nurse performed wound care of the resident's left heel, 90% of eschar with 10% slough wound measure 8 cm x 6cm x 0.2, no warmth, no redness, but odor noted today, dressing done as ordered. A review of the Change in Condition (CIC) note dated 2/22/2026 at 8:17 am, with a concern due to the resident having a fever of 100.1 orally. Nursing observations, evaluation, and recommendations are: The writer assessed the resident and obtained vital signs; the temperature was noted at 100.1. Due to change in condition, writer notified hospice nurse to come to the facility for further assessment. Writer also informed hospice nurse that resident wound requires assessment.Unstageable pressure ulcer-Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. A stable (dry or adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. https://www.ncbi.nlm.nih.gov/books/NBK2650/table/ch12.t2/.Deep tissue pressure injury remains one of the most serious forms of pressure injury. The pressure is exerted at the muscle-bone interface, but because of the skin's resilience, the color change is not immediate, unlike a bruise. The process leading to deep tissue pressure injury precedes the visible signs of purple or maroon skin by about 48 hours. Then about 24 hours later, the epidermis lifts and reveals a dark wound bed. This phase of deep tissue injury evolution is often confused with skin tears. Within another week, the wound bed is often necrotic. The lag between the pressure event and the change in color of the skin makes the root cause analysis complex. The National Pressure Injury Advisory Panel (NPIAP) has created the photographic timeline shown above to help clinicians more reliability determine the events leading to deep tissue pressure injury. It is important to be aware that 48 hours prior to the patient's skin being deep red, maroon, or purple, he/she may not have been in your facility. https://npiap.com/news/546664/Evolution-of-Deep-Tissue-Pressure-Injury.htmOn 2/20/26 at approximately 5:00 pm, during the end-of-day meeting, the above information was shared with the DON, Administrator, and Regional Nurse Consultant. The DON said that the residents' wounds are progressing even though the nurses are doing the treatments. The DON also mentioned that hospice and the healing agency started working together. The DON also said that the resident was in comfort care prior to the wounds due to her overall health.On 2/21/26 at approximately 5:35 pm, an interview was conducted with License Practical Nurse (LPN) #2. LPN #2 said that the unstageable wound on the resident's left buttock was found on 2/04/26 by a Certified Nursing Assistant (CNA). LPN #2 also said on 1/21/26, the resident had redness on her buttock, which was brought to her attention by a CNA. The LPN stated, I forgot to document it; it was later brought to another staff member's attention. It wasn't mentioned until 2/04/26. LPN #2 also mentioned that the hospice nurse came in today and started the resident on Doxycycline and stated, The Heel wound was found as a DTI initially; it was treated with skin prep and betadine, but deteriorated 2 or 3 weeks afterwards and developed Eschar. Hospice normally doesn't come out on the weekend. The hospice nurse didn't write anything concerning the heel wound.On 2/22/26 at approximately 10:00 am, the facility staff informed the surveyor that the hospice nurse was in Resident #71's room getting ready to perform wound care. The surveyor knocked and was asked to come in by the facility staff. The hospice nurse was getting ready to perform wound care. The surveyor asked the hospice nurse if she could speak to her in the conference room after the wound care was completed. The hospice nurse said I don't feel comfortable talking to a surveyor. The surveyor exited the resident's room and informed the facility staff of what was said by the hospice nurse. The Regional Nurse said that she would immediately contact the hospice nurses' supervisor.On 2/22/26 at approximately 10:35 am, the Hospice Case Manager (HCM) entered the conference room, stating that she had her director on speaker phone. The Director of Hospice (DOH) said that Resident #71 was diagnosed as having Senile Degeneration of the brain. The HCM said that she had gotten a call from the facility yesterday saying they needed someone to assess the resident's left buttock wound because it looked like it was infected. The HCM said the buttock wound was bright red, warm to the touch, got doxycycline, pulled dressing measured 7x6 100% necrotic, foul odor, no drainage. She stated, This morning, I got a call at 8:19 am., They (facility) said she's running a fever of 101. They needed me to re-assess the wound bc they didn't have measurements. Hip still looks the same, redness, odor, mild swelling re-measured 7.5 x 7. Still the same I have only known Kennedy ulcers to be in the sacral area. Low-grade temp 99.4. It is not diagnosed as a [NAME] Ulcer. Not officially on Hospice caseload, officially admitted to hospice-2/11/26-initial nursing assessment. The same treatment- Santyl.On 2/22/26 at approximately 4:45 PM, a final interview was conducted with the Administrator, DON, and the Regional Nurse Consultant. The above concern was addressed, and an opportunity was offered for the facility's staff to provide information they considered pertinent to the findings.

Based on information acquired while reviewing infections acquires in the facility and staff interviews the facility staff failed to have a qualified individual to perform the role of an Infection preventionist (IP). The findings included; On 7/3/24 at approximately 1:05 PM, an interview was conducted with the Registered Nurse identified as the IP. As the documentation was reviewed regarding urinary tract infections (UTI) for residents over a six month period two residents were identified with multiple UTIs. The IP stated staff education was provided without providing documentation of the curriculum. During the interview, the IP also stated that she had completed the training to become a qualified IP but, she did not have the certification because she had not completed the competency test. The IP stated based on information obtained from Human Resources the last qualified IP employed separated from the facility on 12/22/23 and currently she was wearing thehat as the current IP. On 7/8/24 at approximately 1:00 PM, a final interview was conducted with the Administrator, Director of Nursing and Regional Nurse Consultant. They had no comments and voiced no concerns regarding the above information.

Based on resident interview, staff interview, facility documentation review, and clinical record review, the facility staff failed to administer pain medication to a resident who experienced pain and requested pain medication for one (1) of eight (8) residents in the survey sample, Resident #7. The findings include: For Resident #7 the facility staff failed to give pain medication when requested. The resident went without pain medication for approximately 38 hours. Resident #7 was admitted to the facility on [DATE] with diagnoses included but are not limited to left leg pain, peripheral vascular disease (PVD), right below the knee amputation (BKA), left heel unstageable pressure ulcer, and a stage three (3) sacrum pressure ulcer. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 12/8/23 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible score of 15 which indicated Resident #7 was cognitively intact. Section J Health Conditions/Pain Management was not assessed on the MDS. Resident #7 care plan dated 12/21/2023 included a focus on the risk for alteration in comfort related to PVD, left second toe amputation, right BKA, and pressure ulcers. Resident #7 order summary includes an order dated 12/29/23 for Oxycodone (oxycontin) 10mg every four (4) hours as needed for pain. An interview was conducted with Family Member (FM) #1 over the phone on 7/3/24 at approximately 4:15 PM. FM #1 shared that Resident #7 called her on 1/24/24 at approximately 1:00 AM and shared that he had been asking for pain medication for hours and that the nursing staff kept telling him that he was given medication already and that he was not due to get another dose. During this call FM #1 said she could hear staff in the background saying that Resident #7 was given Percocet (oxycodone/acetaminophen). FM #1 said that she informed nursing staff that Resident #7 was allergic to Percocet. FM #1 shared that after the nursing staff checked the medical records, they realized that it was another resident that received pain medication and not Resident #7. An interview was conducted with Resident #7 over the phone on 7/3/24 at approximately 4:25 PM. Resident #7 said that he suffered in pain for hours and that his pain on a scale of 0-10, with 10 being the worse was a 15. An interview was conducted over the phone with Licensed Practical Nurse (LPN) #5 on 7/3/24 at approximately 10:35 AM. LPN #5 shared that she was supervising on 1/24/24 and that Resident #7's daughter called and asked why her father could not get pain medication. LPN #5 said that she did not remember everything, but she remembers there being some confusion about Resident #7 getting pain medication and that the primary nurse had mixed up her residents. Progress note dated 1/24/24 at 1:57 AM written by LPN #4 indicated, Resident #7 requested pain medication and when the medication administration record (MAR) and narcotic book was checked she thought it noted that Resident #7 received pain pills at 12:00 AM. This note also indicates, the 3-11 PM nurse reported that Resident #7 received medication on previous shift and will receive next dose in 4 hours as ordered. The progress note read, Resident #7 insisted that he did not receive his pain medication and called daughter. The nursing supervisor visited the resident and explained to the resident and daughter that she would follow up on the administration time. The nursing supervisor and LPN #4 double checked the narcotic book and realized that the medication was not given to the resident. LPN #4 and the nursing supervisor apologized for the miscommunication. LPN #4 looked at the wrong charting in the narcotic book. LPN #4 administered pain medication to Resident #7 as prescribed. Progress note dated 1/24/24 at 1:58 AM written by the nursing supervisor supported the note written by LPN #4. Review of Resident #7's January MAR indicates prior to Resident #7 calling FM #1 due to pain on 1/24/24 at approximately 1:00 PM, his last dose of Oxycodone was on 1/22/24 at 11:46 AM. After nursing staff recognized their mistake Resident #7 was administered Oxycodone 10mg on 1/24/24 at 1:52 AM, 6:23 AM, 11:52 AM, and 4:56 PM. Review of the facilities Pain Management policy, reviewed and revised on 12/13/23 read, .The facility must ensure that pain management is provided to residents who require such services . An interview was conducted with the Director of Nursing (DON) on 7/8/2024 at approximately 11:30 AM. The DON shared that the expectation is that staff do a pain assessment on every resident every shift at least. The DON indicated that the electronic medical record (EMR) does not populate a pain assessment column if the provider does not order pain assessments. The DON said that the staff had to document their pain assessments otherwise manually. The above findings were shared with the Administrator, Corporate Nurse #1, DON, and Assistant Director of Nursing (ADON) on 7/8/2024 at approximately 5:22 PM. No further information was provided prior to the conclusion of the survey.

49455 Based on staff interview, facility documentation review, and clinical record review, the facility staff failed to document administered controlled medication on the medication administration record (MAR) for one (1) of eight (8) residents in the survey sample, Resident #7. The findings include: For Resident #7 the facility staff failed to document 50 doses of oxycodone on the Medication Administration Record (MAR) that were signed out on the medication monitoring control records for December 2023 and January 2024. Resident #7 was admitted to the facility on [DATE] with diagnoses included but are not limited to left leg pain, peripheral vascular disease (PVD), right below the knee amputation (BKA), left heel unstageable pressure ulcer, and a stage three (3) sacrum pressure ulcer. Resident #7 care plan dated 12/21/2023 included a focus on the risk for alteration in comfort related to PVD, left second toe amputation, right BKA, and pressure ulcers. Review of Resident #7's medication monitoring control records for the months December 2023 and January 2024 reflect oxycodone being signed out but not documented on the December 2023 and January 2024 MARs for the following dates and times: 12/12/23 at 9 PM, 12/13/23 at 6 PM, 12/13/23 at 11 PM, 12/18/23 at 7 AM, 12/18/23 at 6 PM, 12/19/23 at 6 PM, 12/20/23 at 5 PM, 12/21/23 at 6:30 AM, 12/21/23 at 6 PM, 12/22/23 at 5 AM, 12/22/23 at 1:40 PM, 12/22/23 at 8:40 PM, 12/23/23 at 4:30 PM, 12/25/23 at 2:15 AM, 12/26/23 at 9 AM, 12/27/23 at 10:30 AM , 12/28/23 at 7 PM, 12/29/23 at 6 AM, 12/29/23 at 4:56 PM, 12/30/23 at 6 AM, 12/30/23 at 10:00 AM, 12/31/23 at 3 AM, 1/1/24 at 4 PM, 1/1/24 at 10 PM, 1/3/24 at 7 PM, 1/5/24 at 4:30 AM, 1/6/24 at 6:30 PM, 1/15/24 at 5 PM, 1/15/24 at 10 PM, 1/20/24 at 5:30 PM, 1/20/24 at 11 PM, 1/21/24 at 11 AM, 1/21/24 at 3 PM, 1/21/24 at 7 PM, 1/21/24 at 11 PM, 1/22/24 at 7:15 AM, 1/22/24 at 11:15 AM, 1/22/24 at 6 PM, 1/22/24 at 11:46 PM, 1/24/24 at 11 PM, 1/25/24 at 6 AM, 1/25/24 at 10:45 AM, 1/25/24 at 4 PM, 1/25/24 at 10 PM, 1/26/24 at 3:03 PM, 1/27/24 at 4:15 AM, 1/27/24 at 9 AM, 1/27/24 at 4:15 PM, 1/27/24 at 11:45 PM, 1/28/24 at 9 AM, and 1/26/24 at 10 PM. An interview was conducted with the Director of Nursing (DON) on 7/8/2024 at approximately 11:30 AM. The DON shared that when administering a controlled as needed medication, staff should check the order, dispensed medication, sign it off on the narcotic sheet, and document it on the MAR. The DON shared that they did not have a process in place for auditing the controlled sheets but will be developing a process moving forward. An interview was conducted with Licensed Practical Nurse (LPN) #3 on 7/8/24 at approximately 12:00 PM. LPN #3 shared that she developed a bad habit of not always documenting her controlled medication in residents MAR because of feeling rushed at times and the fast-paced flow of her shifts. LPN #3 shared that she was educated on 6/5/24 by the Director of Nursing (DON) of the expectation of complete documentation of administered medications. The above findings were shared with the Administrator, Corporate Nurse #1, DON, and ADON on 7/8/2024 at approximately 5:22 PM. No further information was provided prior to the conclusion of the survey.

Based on staff interview and facility document review, the facility staff failed to maintain a complete infection control surveillance program. The facility staff failed to maintain a complete surveillance system with enough data collection to properly track infections. The findings include: A review of the facility infection control surveillance program for January 2022 through June 2022 revealed the following: -Folders for January 2022 through April 2022 only contained a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription, lab tests results related to various infections for various residents and a color coded facility floor plan that tracked infections by categories of urinary infections, respiratory infections, gastrointestinal infections skin infections and other infections. -A folder for May 2022 only contained a log that tracked infection type, a list of residents that were prescribed an antibiotic and information regarding the antibiotic prescription. -No documentation for June 2022. On 8/3/22 at 4:14 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the infection control nurse who had been employed in that position for two weeks). LPN #4 stated each day she pulls a list of residents receiving antibiotics, including residents who are newly prescribed antibiotics. LPN #4 stated she also pulls any related lab test results related to the infection the antibiotic is prescribed for. LPN #4 stated she then tracks the types of infections based on the color coded floor plan. On 8/4/22 at 10:58 a.m., an interview was conducted with ASM (administrative staff member) #2 (the director of nursing). ASM #2 stated that every morning the team looks at residents who are newly prescribed antibiotics. ASM #2 stated the surveillance program should include a list of residents who have an infection, what infection the resident is diagnosed with, labs, diagnostics, whether the infection is hospital acquired or facility acquired, a facility tracking map and a formula to calculate the percentage of facility acquired infections. ASM #2 stated the purpose of infection surveillance is to see if there is a trend of infections so interventions can be implemented to prevent outbreaks. On 8/3/22 at 5:39 p.m., ASM #1 (the administrator) and ASM #2 were made aware of the above concern. The facility policy titled, Infection Surveillance documented, A system of infection surveillance serves as a core activity of the facility's infection prevention and control program. Its purpose is to identify infections and to monitor adherence to recommended infection prevention and control practices in order to reduce infections and prevent the spread of infections. Definitions: 'Infection surveillance' refers to an ongoing systematic collection, analysis, interpretation, and dissemination of infection-related data .6. Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. 10. Formulas used in calculating infection rates will remain constant for a minimum of one calendar year . No further information was presented prior to exit.

Based on staff interview and facility document review, the facility staff failed to conduct COVID-19 testing in a manner consistent with professional standards of practice. The facility staff failed to conduct complete COVID-19 testing during a facility outbreak that began on 6/10/22. The findings include: A review of facility documentation revealed the facility began COVID-19 outbreak status on 6/10/22 because a resident tested positive. A review of facility testing documentation revealed the following: On 6/10/22, all residents were tested and eight residents were positive for COVID-19. No staff were tested . On 6/13/22, only residents who were symptomatic or exposed were tested . Ten residents were positive. On 6/14/22, one staff member was tested and the results of the test were not documented. On 6/17/22, seven staff were tested and one was positive. On 6/20/22, eight staff were tested and all were negative. On 6/29/22, seven staff were tested and all were negative. On 7/1/22, one resident was symptomatic, tested and was positive. The resident's roommate was also tested and was negative. On 7/7/22, four staff were tested . Three were negative and one staff member's results were not documented. On 7/8/22 one staff was tested and was negative. On 7/10/22, five residents were symptomatic, tested and were positive. On 7/11/22, seven staff were tested and one was positive. On 7/18/22, four staff were tested and were negative. On 7/20/22, one resident was symptomatic, tested and was positive. One staff was tested and was negative. Two other residents were exposed, tested and were negative. On 7/24/22, one resident was symptomatic, tested and was positive. On 7/25/22, seven staff were tested . Six were negative and one staff member's results were not documented. On 8/3/22 at 1:49 p.m., an interview was conducted with LPN (licensed practical nurse) #4 (the infection control nurse who was employed in that positon for two weeks). LPN #4 stated she was informed to conduct COVID-19 testing once a week for staff who were not vaccinated or had not received a booster vaccine. LPN #4 stated that only residents who were symptomatic were being tested and no outbreak testing had been completed. On 8/3/22 at 2:18 p.m., an interview was conducted with ASM (administrative staff member) #1 (the administrator). ASM #1 stated that symptomatic residents and staff, anyone who had been at risk of being exposed, and staff who were exempted from the COVID-19 vaccine were being tested during the facility outbreak. On 8/3/22 at 3:23 p.m., an interview was conducted with ASM #2 (the director of nursing). ASM #2 stated the outbreak began on 6/10/22, when a resident was tested and was positive. ASM #2 stated the resident's family member was positive and had been all over the building so broad based testing was completed on 6/10/22. On 8/3/22 at 4:29 p.m., a telephone interview was conducted with OSM (other staff member) #9 (the local health department representative), in regards to COVID-19 outbreak testing. OSM #9 stated a facility can do either contact tracing or broad based testing but if a facility begins with broad based testing then they have to continue with broad based testing. OSM #9 stated that with broad based testing, all residents and staff should initially be tested at the beginning of the outbreak, then all staff and residents should be tested at least every seven days until there is a 14 day period with no new positive cases. OSM #9 stated the facility administrator had contacted her regarding positive cases but she requested additional information and did not receive a response. On 8/3/22 at 5:39 p.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. On 8/4/22 at 11:23 a.m., an interview was conducted with ASM #5 (the regional director of clinical services). ASM #5 stated that if a facility begins with broad based testing during an outbreak then all residents should initially be tested , then all residents who have not been positive in the last 90 days should be tested every five to seven days until there are no positive cases for two weeks. ASM #5 stated staff should be tested based on the community based cadence unless someone is symptomatic. ASM #5 stated the facility should also follow the local health department recommendations. The CDC (Centers for Disease Control) website documents the following: New Infection in Healthcare Personnel or Residents When performing an outbreak response to a known case, facilities should always defer to the recommendations of the jurisdiction's public health authority .Alternative, broad-based approach: If a facility does not have the expertise, resources, or ability to identify all close contacts, they should instead investigate the outbreak at a facility-level or group-level (e.g., unit, floor, or other specific area(s) of the facility). Broader approaches might also be required if the facility is directed to do so by the jurisdiction's public health authority, or in situations where all potential contacts are unable to be identified, are too numerous to manage, or when contact tracing fails to halt transmission. Perform testing for all residents and HCP (health care personnel) on the affected unit(s), regardless of vaccination status, immediately (but generally not earlier than 24 hours after the exposure, if known) and, if negative, again 5-7 days later. This information was obtained from the website: https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Fnursing-homes-facility-wide-testing.html#anchor_ 858 The facility policy titled, Coronavirus Prevention and Response documented, 5. When COVID-19 is suspected or confirmed the facility will: e. Implement procedures, including, but not limited to, contact testing and tracing, to identify and monitor others who may have been exposed if COVID-19 is confirmed .9.a. Any staff or resident with symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test immediately. b. Asymptomatic HCP (health care personnel) with a higher-risk exposure and residents with close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests. Testing is recommended immediately (but not earlier than 24 hours after the exposure) and, if negative, again 5-7 days after the exposure . No further information was presented prior to exit.

Based on staff interview, facility document review, employee record review, and in the course of a complaint investigation, it was determined the facility staff failed to complete criminal background checks on 7 out of 25 employee records reviewed. The findings include: Twenty five employee records were reviewed. Seven of the twenty five employee records failed to evidence the completion of a criminal background check, OSM (other staff member) #14, central supply clerk; OSM #15, physical therapist; LPN (licensed practical nurse) #9; OSM #17, dietary aide; LPN #12; CNA (certified nursing assistant) #10; and OSM #6, the business office manager/human resources staff member. Two of the seven employees were still employed at the facility, LPN #9 and OSM #6. An interview was conducted with OSM #6 on 8/4/2022 at 7:58 a.m. When asked the process for a new hire, OSM #6 stated in the beginning after the new employee has their interview, we get their identification information, social security number, and vaccination card is submitted to us. Then we run the background check using their ID and social security number. When all information is back, we set them up for orientation. When asked why there are missing criminal background checks, OSM #6 stated she gave us all the documents she could find. OSM #6 stated, she couldn't run her own criminal background check. The previous human resources person had not completed it prior to her starting employment at the facility. The facility policy, Abuse, Neglect and Exploitation documented in part, The components of the facility abuse prohibition plan are discussed herein: 1. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation of resident property; 1. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants .3. The facility will maintain documentation of proof that the screening occurred. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. Complaint deficiency.

Based on staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to implement their policies for the investigation of an allegation of abuse for one of 43 residents in the survey sample, Resident #26; and failed to implement their policies for the investigation of an injury of unknown origin for one of 43 residents in the survey sample, Resident #5 (R5); and failed to implement their policies for the completion of criminal background checks for 7 of 25 employee record reviews. The findings include: 1. The facility staff failed to implement their policies for the investigation of an allegation of abuse, at the time the allegation was made by the resident, for Resident #26 (R26). On the most recent MDS (minimum data set) assessment, with an ARD of 5/30/2022, the resident scored a 15 out of 15 on the BIMS score, indicating the resident was not cognitively impaired for making daily decisions. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R26). Incident Type: Allegation of abuse/mistreat. Describe incident: (R26) report that a big black man had come into her room and threw her on the bed and they all jumped on her .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R26) was unable to accurately recall detailed of the event as well as the names of the alleged employees involved. She stated that she is very confused and has difficulties remembering things. (Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents and does not know who (R26) is. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R26) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2020 at 7:37 a.m., documented in part, Note Text: @ (at) 0255 (2:55 a.m.) resident noted to have bleeding and bruising above right eyelid at nursing station. Resident noted to have 2 shallow lacerations above right eye lid. Injury unwitnessed. Resident very poor historian. Injury was not noted earlier in shift. Resident came from room. Resident's floor noted to have blood on it. Resident clothes scattered on floor. Attempt to clean lacerations and measure them. Resident refused. Walking away from nursing staff. Resident noted to be agitated. No change in behavior when normally agitated. Resident refused vital signs and neuro check to be taken. ADON (assistant director of nursing) notified of above. (Name of physician group) call at 0330 (3:30 a.m.) awaiting callback. 0520 (5:20 a.m.) Received callback from (Name of physician group) notified of the above. 0540 (5:40 a.m.) Received callback from (name of physician group) (name of NP - nurse practitioner) to send resident to ER (emergency room ) via 911 for evaluation. 0540 (5:40 a.m.) 911 called. 0555 (5:55 a.m.) EMS (emergency medical services) arrived and assessed resident. Resident refused to go to ER. ADON notified. Called and left VM (voice mail) to notify (name of physician group) of above. The Skin Condition Observation Sheet, dated 11/5/2020, five days after the initial reported incident, documented the following: 2 x 1 (in centimeters) bruising/black purple noted on right eye; two lacerations in the eyebrow area, scattered bruising on right forearm; swollen right hand; 0.3 x 0.1 area on left chest; 2x1.5 bruising on left antecubital area; 1 x 1.5 area on left arm below the elbow; 0.5 x 0.5 area on left wrist; 1.2 x 2 area noted on right abdomen. None of the staff that were involved in this incident were employed at the facility at the time of survey. This included the administrator, director of nursing, the nurse that wrote the above note, the CNAs documented in the FRI and the ADON. An interview was conducted with LPN (licensed practical nurse) # 5, on 8/3/2022 at 10:42 a.m. When asked the process for when a resident makes a statement that they have been abused, LPN #5 stated you have to initiate an investigation immediately. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. LPN #5 stated that if the resident named a staff member then that staff member would be placed on suspension. When asked if you have to report an allegation of abuse to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if the allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. The facility policy, Abuse, Neglect and Exploitation, documented in part, V. Investigation of Alleged Abuse, and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation. B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in the handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegation; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent and cause and 6. Providing complete and thorough documentation of the investigation. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. 2. The facility staff failed to implement their policies for the investigation of an injury of unknown origin for Resident #5 (R5). On the most recent MDS assessment, a quarterly assessment, with an ARD of 5/4/2022, the resident scored a 0 out of 15 on the BIMS score, indicating the resident is severely cognitively impaired for making daily decisions. In Section G - Functional Status, the resident was coded as requiring extensive assistance to being totally dependent upon the staff for all of their activities of daily living. The Facility Reported Incident (FRI) dated, 11/4/2020, documented in part, Report date: 11/4/2020. Residents involved: (Name of R5). Incident Type: Allegation of abuse/mistreat; injury of unknown origin. Describe incident: (R5) injury of unknown origin. Resident unable to inform staff how bruise to her chest occurred .Resident was fully assessed by nursing staff and bruises were all properly documented. Responsible party and physician were notified. Findings on investigation will be reported back in 5 working days. The Facility Reported Incident (FRI) dated, 11/11/2020, documented in part, All staff on 3-11 and 11-7 were interviewed on whether they had witnessed or had knowledge of the incident in question. Statements were collected from all staff that did indicate that they had knowledge of the incident. A thorough head to toe assessment was completed on both residents, injuries and or bruises were all documented at that time. APS (adult protective services) worker (name of APS worker) and (name of detective) interviewed each resident and took pictures of all injuries/bruises .(R5). (R5) was unable to recall details of the event or how she got her bruises .(Name of a male CNA) called top speak with HR (human resources) on 11/10/2020 and informed her that they were resigning effective immediately and that he never works with female residents and does not know who (R26) is. Statement from the 3-11 CNA (certified nursing assistant) indicated that (R5) was sitting at the nurse's station at the end of the shift free of any injuries and or bruises .The facility has unsubstantiated the allegation against the male CNA. MD (medical doctor) and RP (responsible party) were made aware of the outcome of the investigation. The nurse's note dated, 11/1/2022 at 8:10 a.m. documented, Note Text: CNA giving care requested this nurse to assess resident, upon assessment noted bruised area to left clavicular area, purple in color, non-tender to touch, skin tear to right upper arm, approximately 1.5 in length, purple in color, cleansed with DWC (wound cleanser), pat dry, applied [MEDICATION(S)], then covered with dry dressing. MD made aware/RP (name of RP) notified. Treatment initiated. Will continue to monitor status. There were no skin assessments for around the date above in the clinical record. There were no skin assessments documented in the FRI investigation folder. The only documentation, other than on the actual FRI of 11/4/2020, in the FRI investigation folder was related to the other resident documented on the FRI, not R5. An interview was conducted with LPN (licensed practical nurse) #5, on 8/3/2022 at 10:42 a.m. When asked the process for when a nurse finds an injury of unknown origin on a resident, LPN #5 stated you have to initiate an investigation as to where the injury came from. An incident report must be made. LPN #5 stated a full body assessment must be completed, notify the MD and RP (responsible party). Interview the people that cared for the resident, if the roommate is alert and verbal, would interview them. When asked if you have to report an injury of unknown origin to the director of nursing (DON) or the administrator, LPN #5 stated that a nurse should report it to the DON or administrator as soon as you are aware of it. An interview was conducted with ASM (administrative staff member) #1, the administrator, on 8/4/2022 at 11:19 a.m. When asked what steps are to be taken when a resident stated they have been abused, ASM #1 stated everyone stops what they are doing. First make sure the resident is safe, no injuries, no harm. Report a FRI. We have two hours to report abuse, start an investigation depending on what it is, if staff is involved, suspend the staff member. Question the resident and roommate. ASM #1 stated she takes a census sheet and the staff assignment sheet and start interviews with everyone on that group assignment. ASM #1 stated she would interview the whole hall of residents. Make sure the doctor and family is aware. Complete the investigation, if allegation is founded, then we notify the police. When asked when she should be notified of an allegation of abuse, ASM #1 stated as soon as it happens. When asked if this procedure is the same for an injury of unknown origin such as a bruise, ASM #1 stated, yes, because that could have been caused by abuse. ASM #1 stated she could not locate any further documentation related to the bruises found on R5. The facility policy, Abuse, Neglect and Exploitation documented in part, IV - Identification of Abuse, Neglect and Exploitation: B. Possible indicators of abuse include; but are not limited to: 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body. 3. Physical injury of a resident, of unknown source V - Investigation of alleged Abuse, Neglect and Exploitation: A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur .Vii. Reporting/Response: A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes; a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit. 3. The facility staff failed to implement their policies for the completion of criminal background checks for 7 of 25 employee record reviews. Twenty five employee records were reviewed. Seven of the twenty five employee records failed to evidence the completion of a criminal background check, OSM (other staff member) #14, central supply clerk; OSM #15, physical therapist; LPN (licensed practical nurse) #9; OSM #17, dietary aide; LPN #12; CNA (certified nursing assistant) #10; and OSM #6, the business office manager/human resources staff member. Two of the seven employees were still employed at the facility, LPN #9 and OSM #6. An interview was conducted with OSM #6 on 8/4/2022 at 7:58 a.m. When asked the process for a new hire, OSM #6 stated in the beginning after the new employee has their interview, we get their identification information, social security number, and vaccination card is submitted to us. Then we run the background check using their ID and social security number. When all information is back, we set them up for orientation. When asked why there are missing criminal background checks, OSM #6 stated she gave us all the documents she could find. OSM #6 stated, she couldn't run her own criminal background check. The previous human resources person had not completed it prior to her starting employment at the facility. The facility policy, Abuse, Neglect and Exploitation documented in part, The components of the facility abuse prohibition plan are discussed herein: 1. Screening: A. Potential employees will be screened for a history of abuse, neglect, exploitation or misappropriation of resident property; 1. Background, reference and credentials' checks shall be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers and consultants .3. The facility will maintain documentation of proof that the screening occurred. ASM (administrative staff member) # 1, the administrator, ASM #2, the director of nursing, and ASM #5, the director of clinical services, were made aware of the above concern on 8/4/2022 at 11:46 a.m. No further information was obtained prior to exit.

2. The facility staff failed to develop a comprehensive care plan for treatment and care of (R36's) pressure ulcer. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 06/10/2022, the resident scored 0 (zero) out of 15 on the BIMS (brief interview for mental status), indicating the resident was severely impaired of cognition for making daily decisions. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive care plan for (R36) dated 07/23/2022 failed to evidence documented for care and services for (R36's) sacral pressure ulcer. On 08/04/22 at approximately 11:24 a.m., an interview was conducted with LPN (licensed practical nurse) #5. When asked if there was a care plan that addressed (R36's) sacral pressure ulcer and the use of pressure reducing boots LPN #5 review (R36's) current comprehensive care plan and stated that there was no care plan for (R36's) pressure ulcer or the boots. When asked to describe the procedure for developing a care plan for (R36's) pressure ulcer LPN #5 stated that nursing or the MDS coordinator should have developed the care plan from the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/04/2022 at approximately 11:24 a.m., LPN #5 provided page 16 of (R36's) comprehensive care plan that documented, Focus: (R36) actual impairment of the skin integrity r/t left heel open area , open area to sacrum. Date Initiated: 07/23/2022. Revision on: 08/04/2022. On 08/0/2022 at approximately 11:40 a.m., ASM # 1, administrator ASM # 2, director of nursing, and ASM # 5, regional director of clinical services, were made aware of the above findings. No further information was presented prior to exit. 3. The facility staff failed to develop a comprehensive care plan for (R38's) use of oxygen. (R38) was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 06/15/2022, the resident scored 6 (six) out of 15 on the BIMS (brief interview for mental status), indicating the resident is severely impaired of cognition for making daily decisions. Section O Special Treatments, Procedures and Programs coded (R38) for Oxygen Therapy while not a resident. On 08/02/22 at approximately 12:58 p.m., an observation of (R38) revealed they were sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. On 08/02/22 at approximately 2:58 p.m., an observation of (R38) revealed they were sitting in their room in a wheelchair receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. On 008/03/22 approximately 8:14 a.m., an observation of (R38) revealed they were lying in their bed receiving oxygen by nasal cannula. Observation of the flow meter on the oxygen concentrator revealed a flow rate between two and two-and-a-half liters per minute. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] @ 2lpm (oxygen at two liters per minute) via (by) n/c (nasal cannula), prn (as needed) for sats (saturation). Review of the (R38's) comprehensive care plan dated 06/09/2022 failed to evidence care and services for oxygen administration. On 08/04/22 at approximately 8:03 a.m., an observation of (R38's) oxygen flow rate on the oxygen concentrator was conducted with LPN (licensed practical nurse) #5. When asked if there was a care plan for the use of oxygen for (R38) LPN # 5 review (R38's) current comprehensive care plan and stated that there was not care plan for (R38's) use of oxygen. When asked to describe the procedure for developing a care plan for (R38's) oxygen LPN #5 stated that nursing or the MDS coordinator should have developed the care plan from the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On 08/04/2022 at approximately 8:20 a.m., LPN #5 provided page 14 of (R38's) comprehensive care plan that documented, Focus: The resident has oxygen therapy r/t (related to) Ineffective gas exchange. Date Initiated: 08/04/2022. Under interventions it documented, Monitor for s/sx (signs and symptoms) of respiratory distress and report to MD (medical doctor) PRN (as needed): Respirations, Pulse oximetry, Increased heart rate ([CONDITION(S)]), Restlessness, Diaphoresis, Headaches, Lethargy, Confusion, Atelectasis, Hemoptysis, Cough, Pleuritic pain, Accessory muscle usage, Skin color. Date Initiated: 08/04/2022; OXYGEN SETTINGS: O2 via nasal cannula @ 2L as needed. Date Initiated: 08/04/2022. Revision on: 08/04/2022; Promote lung expansion and improve air exchange by positioning with proper body alignment. If tolerated, head of bed elevated to 30 degrees. Date Initiated: 08/04/2022. Revision on: 08/04/2022 On 08/0/2022 at approximately 11:40 a.m., ASM # 1, administrator ASM # 2, director of nursing, and ASM # 5, regional director of clinical services, were made aware of the above findings. No further information was presented prior to exit. 4. The facility staff failed to follow Resident 73's (R73's) care plan for the administration of oxygen. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 7/13/22, R73 was coded as being moderately impaired for making daily decisions, having scored 11 out of 15 on the BIMS (brief interview for mental status). R73 was coded as having received oxygen at the facility during the look back period. R73's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On the following dates and times, R73 was observed lying in bed, with oxygen being delivered at 3 lpm (liters per minute) via nasal cannula per oxygen concentrator: 8/2/22 at 12:35 p.m. and 3:00 p.m.; 8/3/22 at 8:02 a.m. and 10:37 a.m. A review of R73's care plan dated 1/14/22 and revised on 7/14/22 revealed, in part: [R73] has orders for oxygen therapy - on 2L/NC (two liters per minute via nasal cannula). A review of R73's clinical record revealed no evidence of a provider's order for oxygen administration. On 8/3/22 at 10:21 a.m., LPN (licensed practical nurse) #2 was interviewed. When asked how a nurse knows at what rate to administer oxygen to a resident, she stated she checks the provider's order for the rate. When asked why oxygen administration requires a provider's order, she stated: Because it is a drug. On 8/3/22 at 1:54 p.m., LPN #5, a unit manager, was asked to verify the rate at which R73 should be receiving oxygen. She stated she needed to check the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/3/22 at 1:55 p.m., LPN #2, who was caring for R73 on that shift, was asked to verify the rate at which R73 should be receiving oxygen. LPN #2 checked R73's orders, and stated: I don't see any orders for oxygen. But I'm sure it's two liters [per minute]. LPN #2 re-checked the orders, but found none for the administration of oxygen for R73. LPN #2 checked R73's oxygen rate, and turned the rate on the concentrator from three lpms to two lpms. LPN #2 stated the purpose of a resident's care plan is to tell the staff how best to take care of a resident. She stated everyone is responsible for implementing each resident's care plan. She stated the facility staff had not been following R73's care plan for oxygen administration. On 8/3/22 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. No further information was provided prior to exit. 5. The facility failed to follow R6's care plan to evidence coordination of hospice services with the hospice provider. On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/22, R6 was coded as being moderately impaired for making daily decisions, having scored 12 out of 15 on the BIMS (brief interview for mental status). R6 was coded as receiving hospice services during the look-back period. A review of R6's clinical record revealed the following provider's order dated 4/22/22: Admit to [name of hospice company]. A review of R6's care plan dated 5/17/22 revealed, in part: Resident admitted to hospice services .Encourage support system of family and friends .Work with [hospice] nursing staff to provide maximum comfort for the resident. Further review of R6's clinical record failed to reveal a care plan, progress notes, or any other documentation by R6's hospice services provider. On 8/3/22 at 1:54 p.m., LPN (licensed practical nurse) #5, a unit manager, was asked to provide notes and/or other evidence of coordination with R6's hospice provider. LPN #5 stated there was no such documentation. She stated this particular hospice company does not provide notes to the facility. She stated she would need to call the company and asked the company to send the notes by fax. She stated she was aware of the facility's requirement to coordinate care with R6's hospice provider, but stated the company did not comply with that requirement regarding paperwork. On 8/3/22 at 1:55 p.m., LPN (licensed practical nurse) #2 was interviewed. LPN #2 stated the purpose of a resident's care plan is to tell the staff how best to take care of a resident. She stated everyone is responsible for implementing each resident's care plan. On 8/3/22 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. No further information was provided prior to exit. 6. For Resident #34 (R34), the facility staff failed to follow the care plan for anti-tippers to be placed on R34's wheelchair. No anti-tippers were observed on multiple occasions during the survey while R34 was in the wheelchair. On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 6/9/22, R34 was coded as being severely impaired for making daily decisions, having scored 4 out of 15 on the BIMS (brief interview for mental status). R34 was coded as requiring a wheelchair for moving around the room and the unit. On the following dates and times, R34 was observed sitting in a wheelchair: 8/2/22 at 12:47 p.m. and 1:59 p.m.; 8/3/22 at 8:00 a.m. At no time did R34's wheelchair have anti-tip devices on the back to prevent R34's wheelchair from tipping over backwards. A review of R34's care plan dated 10/11/20 and revised 10/17/21 revealed, in part: The resident is at risk for fall R/T (related to): poor balance, unsteady gait, confusion, unaware of safety needs .dementia .antiroll back system to w/c (wheelchair). On 8/3/22 at 1:55 p.m., LPN (licensed practical nurse) #2 was interviewed. LPN #2 stated the purpose of a resident's care plan is to tell the staff how best to take care of a resident. She stated everyone is responsible for implementing each resident's care plan. On 8/4/22 at 8:08 a.m., OSM (other staff member) #3, an occupational therapist and the director of rehab, was interviewed. She stated she was familiar with R34. When asked if R34's wheelchair needed any specialized adaptations, she stated R34 had sustained multiple falls. She stated she had worked extensively with R34, and R34 had no ability to control their own impulses to stand and try to walk. She stated R34 was unsafe to walk independently. She stated R34 needed anti-tippers on the wheelchair to prevent the wheelchair from falling backwards if the resident tried to stand independently. OSM #3 observed R34 in the wheelchair. OSM #3 stated: No, she does not have anything on the wheelchair for extra safety. No anti-tippers. She stated if R34's care plan contained anti-tippers on the wheelchair, then the care plan was not being followed. On 8/4/22 at 12:05 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, and ASM #5, the regional director for clinical services, were informed of these concerns. No further information was provided prior to exit. Complaint deficiency. 7. The facility staff failed to develop the comprehensive care plan for the use of bed rails for Resident #4 (R4). On the most recent MDS (minimum data set), an admission assessment with an ARD (assessment reference date) of 4/29/2022, the resident scored 15 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. On 8/2/2022 at 2:10 p.m., an interview was conducted with R4 in their room. R4 was observed in bed lying on top of the made bed. Bilateral upper quarter bed rails were observed to be in the up position on the bed. R4 stated that they did not really use the rails but sometimes pulled up on them. When asked if staff had discussed the bed rails with them, R4 stated that they may have when they first came in but they did not remember because they had changed rooms. The comprehensive care plan for R4 failed to evidence documentation of bed rail use. The Admission/Re-admission screening dated 4/22/2022 for R4 documented in part, .Side rails, Sides: Neither, Not indicated at this time . The Bed Rail Safety Review dated 4/22/2022 for R4 documented in part, .Have alternative to bed rails been attempted? Yes .Continue current alternative measures . On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plan was updated by the nurse, the unit manager or the MDS staff. LPN #5 stated that the care plan purpose was for the staff to treat the patient according to the plan of care. LPN #5 stated that bed rails should be addressed on the care plan so the staff know that they were a part of their plan of care. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 8. The facility staff failed to develop the comprehensive care plan for the use of bed rails for Resident #23 (R23). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/26/2022, the resident scored 14 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident is cognitively intact for making daily decisions. On 8/2/2022 at 1:16 p.m., an interview was conducted with R23 in their room. R23 was observed in bed. The left upper bed rail was observed to be up on the bed. R23 stated that they used the bed rail to hold onto for positioning. When asked if staff had discussed the bed rails with them, R23 stated that they were not sure if anyone had asked, but they used them. The comprehensive care plan for R23 failed to evidence documentation of bed rail use. The Bed Rail Safety Review dated 6/16/2022 for R23 documented in part, .Have alternative to bed rails been attempted? Yes .Implement new bed rail(s) as indicated to promote independence and safety (Obtain informed consent). List bed rail(s) to be implemented: Quarter rail. List side(s): Both . On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plan was updated by the nurse, the unit manager or the MDS staff. LPN #5 stated that the care plan purpose was for the staff to treat the patient according to the plan of care. LPN #5 stated that bed rails should be addressed on the care plan so the staff know that they were a part of their plan of care. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. 9. The facility staff failed to develop a comprehensive care plan to include (1) the use of bed rails and (2) address activities of daily living for Resident #14 (R14). On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 5/19/2022, the resident scored 13 out of 15 on the BIMS (brief interview for mental status) assessment, indicating the resident was cognitively intact for making daily decisions. Section G documented R14 requiring extensive assistance of one person for dressing, bathing, personal hygiene and toileting. On 8/2/2022 at 3:45 p.m., an interview was conducted with R14 in their room. R14 was observed lying on top of their bed with bilateral upper bed rails up on the bed. R14 stated that they used the bed rails to grab on to when turning. R14 stated that the facility staff were very helpful and assisted them with bathing and personal hygiene. The comprehensive care plan for R14 failed to evidence documentation of bed rail use or address ADL requirements. The Bed Rail Safety Review dated 3/22/2021 for R14 documented in part, .Have alternative to bed rails been attempted? Yes .Implement new bed rail(s) as indicated to promote independence and safety (Obtain informed consent). List bed rail(s) to be implemented: Half rail. List side(s): Both . On 8/3/2022 at 3:58 p.m., an interview was conducted with LPN (licensed practical nurse) #5. LPN #5 stated that the care plan was updated by the nurse, the unit manager or the MDS staff. LPN #5 stated that the care plan purpose was for the staff to treat the patient according to the plan of care. LPN #5 stated that all residents should have a care plan regarding their ADL's (activities of daily living). LPN #5 reviewed R14's care plan and stated that they did not see a care plan regarding the bed rails or the ADL's and that these areas should be addressed. On 8/3/2022 at 5:22 p.m., ASM (administrative staff member) #1, the administrator, ASM #2, the director of nursing, ASM #5, the regional director of clinical services and LPN (licensed practical nurse) #4, the director of clinical education/wound care were made aware of the findings. No further information was provided prior to exit. Based on observation, resident interview, staff interview, facility document review, clinical record review and in the course of a complaint investigation, the facility staff failed to develop and/or implement the comprehensive care plan for 9 of 43 residents in the survey sample, Residents #276, #36, #38, #73, #6, #34, #4, #23 and #14. The findings include: 1. The facility staff failed to implement Resident #276's (R276) comprehensive care plan for wound care treatments per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] On the most recent MDS (minimum data set), a quarterly assessment with an ARD (assessment reference date) of 11/12/21, the resident scored 13 out of 15 on the BIMS (brief interview for mental status), indicating the resident was not cognitively impaired for making daily decisions. R276's comprehensive care plan dated 6/11/21 documented, (Name) has Venous Ulcer r/t (related to) PVD (peripheral vascular disease) to Left medial bunion. Administer treatment/medication as per MD (medical doctor) order. (Name) has Venous Ulcer r/t PVD to Right medial foot. Administer treatment/medication as per MD order. A review of R276's clinical record revealed a note signed by the wound care nurse practitioner on 1/26/22 that documented, Treatment Recommendations: #2 Venous ulcer Hallux left medial- Instructions: Clean with wound cleaner. collagen (1), silver alginate (1), dry dressing and Ace wrap QD (every day) and prn (as needed). #1 Venous ulcer Foot right medial- Freq (Frequency): Daily (QD) & prn. Instructions: Clean with dakins (wound cleansing solution). Santyl (1) ([MEDICATION(S)] (1) until avail [available]), calcium alginate (1), skin prep to peri, dry dressing and wrap with Ace, QD/prn). A review of R276's January 2022 and February 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1/26/22-Clean (L) (left) bunion (venous ulcer hallux left medial) with wound cleaner, apply silver alginate/collagen, skin prep around the wound and cover with dry dressing, and wrap with ace wrapping up to below knees QD and PRN every night shift every other day for wound care. 1/27/22-Clean (R) (right) bunion (venous ulcer foot right medial) with Dakins, apply [MEDICATION(S)] and calcium alginate to wound bed, skin prep around the wound and cover with dry dressing, and wrap with ace wrapping up to below knee QD and PRN every night shift every other day for venous ulcer every day. The treatment to the left bunion was only initialed as completed every other day on 1/26/22, 1/28/22, 1/30/22 and 2/1/22 (the other days were blocked off with an X). The treatment to the right bunion was only initialed as completed every other day on 1/27/22, 1/29/22 and 1/31/22 (the other days were blocked off with an X). R276 discharged from the facility on 2/2/22. On 8/4/22 at 8:06 a.m., an interview was conducted with LPN (licensed practical nurse) #4. LPN #4 stated the wound care doctors and nurse practitioners email their notes to the nurses and the nurses create orders that are based on the notes in the facility computer system. LPN #4 stated the orders carry over to the TARs and nurses complete treatments based on the TARs. LPN #4 stated there is a specific tab in the computer system to block off days on the TARs to instruct nurses to not complete treatments on those days. LPN #4 reviewed the above wound care nurse practitioner note and the above TARs. LPN #4 stated the nurse who entered the order into the computer system set the frequency for treatment as every other day and that is why every other day was blocked off on the TARs. LPN #4 stated that according to the wound care note and the orders, the treatments should have been completed every day but were not. On 8/4/22 at 9:32 a.m., another interview was conducted with LPN #4. LPN #4 stated the comprehensive care plan is the plan of care for the resident and interventions are documented so that all clinicians or anyone working with the resident knows what care the resident needs. LPN #4 stated care plans are implemented on admission and can be reviewed. On 8/4/22 at 11:58 a.m., ASM (administrative staff member) #1 (the administrator) and ASM #2 (the director of nursing) were made aware of the above concern. The facility policy titled, Care Planning-Resident and/or Resident Representative participation documented, 6. The care planning process will include an assessment of the resident's strengths and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care. The policy failed to document specific information regarding care plan implementation. No further information was presented prior to exit. Complaint deficiency. Reference: (1) Collagen, silver alginate, Santyl, [MEDICATION(S)] and calcium alginate are all products used to treat wounds.

Based on observation, staff interview, facility document review and clinical record review, the facility failed to provide an environment free of hazards to prevent accidents for 1 of 17 residents in the survey sample, Resident #10. The facility staff failed to supervise Resident #10 identified as at risk of injury from increased tremors and involuntary muscle movements and served coffee at an excessively hot temperature sufficient to cause second-degree burns to bilateral inner thighs. The findings included: Resident #10 was a [AGE] year old admitted to the facility on [DATE]. The resident's current [DIAGNOSES REDACTED]. *Dementia: a progressive organic mental disorder characterized by chronic personality disintegration, confusion, disorientation, stupor, deterioration of intellectual capacity and function, and impairment of control of memory, judgement, and impulses. *Cerebral Vascular Accident: an abnormal condition of the brain characterized by occlusion by an embolus, thrombus, or cerebrovascular hemorrhage or vasospasm, resulting in ischemia of the brain tissues normally perfused by the damaged vessels. *Parkinson's Disease: a slowly progressive degenerative neurologic disorder characterized by resting tremor, pill rolling of the fingers, a masklike facie's, shuffling gait, forward flexion of the trunk, loss of postural reflexes, and muscle rigidity and weakness. *Dysphagia: difficulty in swallowing, commonly associated with obstructive motor disorders of the esophagus. The above definitions were derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. The most recent Minimum Data Set (MDS) assessment was a quarterly dated 10/31/14 with a Brief Interview for Mental Status (BIMS) scored a 7 out of a possible 15 which indicated that Resident #10 had moderately impaired skills needed for daily decision making. Resident #10 also needed supervision (oversight, encouragement or cueing) with one person physical assist for eating. Under Functional Status the resident was coded to have impairment on one side of the upper and lower extremities. The comprehensive plan of care dated 7/30/12 identified the resident to have activities of daily living deficits based on cognition, and dementia and also was at risk for injury from increased tremors and involuntary muscle movements related to Parkinson's Disease with approaches to include: 1. Offer tray set-up, assist with verbal cueing/feeding as needed. 2. Meal monitoring as needed. 3. Assist with meals as needed. Review of the medical record indicated that Resident #10 was witnessed spilling his nectar-thickened coffee from breakfast into his lap on 1/11/15 while in the dining room. The coffee spill resulted in bilateral second-degree burns to the residents inner thighs that worsened over a two hour time frame resulting in the resident being transferred via rescue squad to the local hospital. The resident returned to the facility from the hospital the same day with new orders to clean the second-degree burns and apply antibiotic ointment, a nonstick dressing and dry dressing every day until healed. *Burn: is defined as any injury to tissues of the body caused by hot objects or flames, electricity, chemicals, radiation, or gases in which the extent of the injury is determined by the nature of the agent, length of time exposed, body part involved and depth of burn. Second-degree burns may be divided into superficial partial-thickness and deep partial-thickness wounds. Damage in second-degree burns extends through the epidermis to the dermis but is usually not sufficient to prevent skin regeneration. The above definition was derived from Mosby's Dictionary of Medicine, Nursing, and Health Professions 8th Edition. Review of the physician orders signed on 12/5/14 revealed an order written [REDACTED]. On 1/11/15 at 7:00 a.m., the Registered Dietitian wrote a recommendation for Resident #10 which read as follows, "Please provide 1:1 feeding assistance due to 9 lb (pound) wt (weight) loss in 3 months (consumption significantly better when assisted)." On 10/24/14 the resident had been evaluated by occupational therapy. The evaluation indicated under precautions that the resident was impulsive, functional deficits were self feeding, and underlying impairments included severely impaired visual/perceptual and memory. During an interview on 1/15/15 at 10:00 a.m. Certified Nursing Assistant (CNA) #2 was asked to explain what happened in the dining room with Resident #10. CNA #2 indicated she was assisting in the dining room that morning with feeding, tray setup, and transporting residents in and out of the dining room. While picking up a tray she saw Resident #10 pick up the coffee cup, she observed he did not have a good grip and the coffee spilt on his lap. CNA #2 explained that she had just poured Resident #10's coffee, and the cup was full. CNA #2 stated that Resident #10 said, "That was hot" when the coffee spilled on his lap. CNA #2 took the resident back to his room to get his assigned CNA to change him. The CNA indicated she and one other CNA were in the dining room during the incident. CNA # 2 indicated she was not aware that the resident required a 1:1 for eating as ordered and assessed by the Registered Dietician earlier that morning. An interview on 1/15/15 at 10:30 a.m. with CNA #1 who was Resident #10's assigned CNA for 1/11/15 on the 7-3 shift stated, "When I got him (Resident #10) up that morning (1/11/2015) he looked like he's not going to feed self or eat, lately he looks like he needs more supervision." When asked to explain this the CNA indicated that she had noted since last week the resident was needing more supervision due to his decrease in alertness. She indicated the resident seemed tired. CNA #1 shared that CNA #2 brought Resident #10 back to his room after the coffee had spilled on his lap, and that CNA #2 assisted her with changing the resident. After removing the resident's sweat pants she observed redness to both inner thighs and immediately called for the nurse. The nurse instructed CNA #1 to apply cold compresses to the reddened inner thigh areas and to keep a check on them. CNA #1 stated, "At 10:30 a.m. I went back to check him and saw the blisters and told the nurse (Licensed Practical Nurse LPN #6)." An interview was conducted with LPN #6 on 1/15/15 at 11:35 a.m. LPN #6 indicated that CNA #1 alerted her that Resident #10 had spilt coffee in his lap and she was needed in his room. LPN #6 stated, "He (Resident #10) had reddened areas with the start of blisters noted on his inner thighs." LPN #6 explained that Unit Manager LPN #3 came over to examine Resident #10's inner thigh areas. She stated the resident needed to go to the hospital to be checked out at which time an order was received and the resident was sent to the hospital. On 1/14/15 at 5:37 p.m. Unit Manager LPN #1 documented the following in Resident #10's medical record, "bilateral blistered areas assessed and measures. right thigh with noted intact, clear, fluid filled blister with blanchable, reddened surrounding skin. no drainage noted. no odor noted. no s/s (signs or symptoms) of infection noted. measurement of 3.5 x 9.0 cm. (centimeters) area cleaned, bacitracin and dressing applied. left upper thigh with intact, clear, fluid filled blister with blanchable, reddened surrounding skin. no drainage noted. no odor noted. no s/s of infection noted. measurement of 1.0 x 3.0 cm. area cleaned, bacitracin and dressing applied. treatment procedure tolerated well. no c/o (complaint of) pain when asked. no grimacing noted." On 1/15/15 at 3:08 p.m. Unit Manager LPN #1 documented the following in Resident #10's medical record, "this nurse went to do treatment to bilateral thigh. unopened blisters noted to be open at this time. right thigh upper area top layer of skin open, with pink, moist tissue noted with red in color, blanchable outer skin, measuring 4.0 x 8.0 cm, no odor noted. right thigh lower, inner open area measuring 1.2 x 1.2 cm area with top layer of skin open with pink, moist tissue noted with red in color, blanchable outer skin, with no odor noted. left thigh area, with top layer skin open with pink moist tissue noted, measuring 1.4 x 4.5 cm, no odor noted. md (medical doctor) called and made aware of wound changes. new order to d/c (discontinue) Opsite treatment. cleanse bilateral thigh open areas with DWC (dermal wound cleaner), apply skin prep to surrounding tissue and apply Xerform to open area, and dry dressing daily and as needed. rp (responsible party) called and message left. An interview was conducted with Resident #10 on 1/15/15 at approximately 2:30 p.m. prior to his thigh treatment being done. This surveyor observed that both bilateral thigh blisters had opened, leaving large moistened reddish-pink wound beds. This surveyor asked the resident if he was having any pain, resident stated, "No." Then asked if the coffee was hot when he spilt it on his lap, resident stated, "Yes." Resident #10 also replied "Yes", when asked if it was painful when he spilt the coffee in his lap. On 1/14/15 at 5:30 p.m. the Dietary Manager was asked to check the temperature of a cup of coffee that had just been poured out of the coffee urn in the dining room for resident dinner consumption. The digital temperature of the coffee in the cup was 141 degrees. On 1/15/15 between 8:10 a.m. and 8:40 a.m., a dining room breakfast observation was conducted. At 8:10 a.m., the Dietary Manager was asked to take the temperature of the coffee in the tan colored unplugged urn. The first temperature was 156-158 degrees, the second temperature was taken with a digital thermometer reached 160.9 degrees. The staff did not check the temperature of the coffee being poured from the urn prior to serving the residents. Resident #10 was observed being served his breakfast tray at 8:16 a.m., no coffee was offered. As soon as Resident #10's tray was placed in front of him he immediately reached for it and started grabbing various food items. The resident exhibited periodic loud coughing throughout the meal. The resident was left unattended and unsupervised from 8:18 a.m. to 8:24 a.m. The January 2015 Coffee Temperature Log was obtained from the Dietary Manager. Based on the document review on 1/11/15 the breakfast coffee temperature was initially 180 degrees when it was transferred from the brewing station to the coffee urn. Approximately twenty to thirty minutes later the second temperature of the coffee was taken in the urn indicating 156 degrees at which time the coffee urn is placed in the dining room for serving to the residents. Per the Dietary Manager this is the daily routine for temperature monitoring of the coffee. A review of the facility policy "Meals-Preparing and Serving", updated 1/2013 documented, in part under the heading Procedures, Item #4: "Nursing personnel check food for appropriate content, texture, and temperature". According to an American Burn Association document entitled Fire and Burn Safety for Older Adults Educator's Guide, under the heading General Background Information ...Risk Factors ...Physical Changes, the document read "Older adults experience a myriad of physical and cognitive changes associated with the aging process that makes them more vulnerable to fire and burn injuries... there are significant changes in sensory perception. The ability to see, hear and feel potential fire and burn dangers diminishes proportionally as one gets older...Since older adults also have thinner skin, they may experience a much deeper burn than a younger person, when exposed to the same amount of flame or other burn injury source.. Under the heading Working with the Older Adult Population, the document continues "With 12.5 % of the population age 65 and older, there is a need to assess and address injury risks affecting them as they age". According to a second document based on the above Burn Association Kit , found at http://www.ameriburn.org/Preven/2000Prevention/Scald2000PrevetionKit.pdf : "The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin... When the temperature of a hot liquid is increased to 140o F / 60o C. it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F./ 71-82o C. degrees, resulting in almost instantaneous burns that require surgery to heal". The two factors addressed above are underscored in a Burn Foundation document retrieved from the Internet : Which states "Hot Water Causes a Third Degree Burns ... ...in 1 second at 156? ...in 2 seconds at 149? ...in 5 seconds at 140? ...in 15 seconds at 133?. https://www.burnfoundation.org/programs/resource.cfm?c=1&a=3 On 1/15/15 at 3:00 p.m., during the pre-exit interview with the Administrator and the Director Of Nursing (DON) the above findings were shared. When asked what change in the facility process had occurred to prevent injuries of this type from occurring again, no response was offered. Also, there was no change in Resident #10's care plan that addressed the prevention of further injury. The DON indicated the nursing staff where inserviced on Resident #10 requiring 1:1 supervision during meals two days after the incident. They both indicated this was conducted based on the Registered Dietician's orders due to weight loss and not safety. The administrator indicated if the CNA had noted there was a change in the resident requiring supervision the CNA should have notified the charge nurse.

Based on clinical record review, staff, and family interviews and in the course of a complaint investigation, the facility staff failed to ensure each resident received the necessary care and services to attain or maintain the highest physical well-being for 1 of 8 residents in the survey sample, Resident #8. The facility staff failed to demonstrate ongoing monitoring, assessments with timely interventions for a recognized change in condition in Resident #8's right leg. The resident's right leg and foot exhibited ischemic (insufficient supply of blood, usually due to a blocked artery) changes, that included multiple blistering, discolorization, pain, including cold to touch and pulseless. Upon evaluation in theER on [DATE] and immediate transfer to another hospital, amputation was recommended and performed on 7/2/12. The findings included: Resident #8 was admitted to the nursing facility on 4/12/11 with [DIAGNOSES REDACTED]. Resident #8 was discharged on [DATE] to the local hospital and did not return to the facility. The Minimum Data Set (MDS) quarterly assessment dated [DATE] coded the resident with short and long term memory and severely impaired in the skills needed for daily decision making. She was not assessed with [REDACTED]. She was coded to require limited assistance from one staff for bed mobility. The resident was assessed for extensive assistance from one staff for transfers, movement on and off the unit, dressing and personal hygiene. She was totally dependent on one staff for toilet use and bathing. She was impaired in range of motion in lower extremities on both sides. A wheelchair was normally used for mobility. There were no assessed skin conditions. The discharge MDS dated [DATE] indicated the resident had one current unstageable pressure ulcer (covered with slough or eschar). The care plan dated as revised on 5/23/12 identified a [DIAGNOSES REDACTED]. The goal of the staff was the resident would have optimal circulatory function with no further complication through next review date. Some of the interventions the staff would use to accomplish this goal included assess extremities for skin discolorization, [MEDICAL CONDITION], dry shiny skin, poor capillary refill, etc and notify the physician. Provide pain medication and monitor for worsening of pain or pain not responding to current therapy and notify the physician as needed. There were no identified existing pressure ulcers on the care plan, but she was identified at risk for them. Electronic nurse's notes were reviewed for the month of May through July 1, 2012 which revealed the following information regarding Resident #8's change in condition in chronological order: "6/30/2012 3:15 pm. The patient's toes were blue this morning. She did not have a pedal pulse (arterial pulse on top of the foot) and they were cool to touch...I paged the on-call physician. (Nurse Practitioner ' s name) returned my call around noon and I reported the change. N.N.O (no new orders). The RP (responsible party was notified as well." This note was signed by LPN #1. "6/30/2012 11:38 pm. Resident's toes and part of foot are dark blue now. Very painful to the touch-cold-no pulse noted. On call has been called. No return call yet. Recommend send to ER." This note was signed by Registered Nurse (RN) #1. "7/1/2012 7:40 am. @ 0705, received order to send pt (patient) out for further eval (evaluation) of right foot, medical transport arranged, report called to (name of local hospital)." This note was signed by RN #2. "7/1/2012 8:00 am. I attempted to contact the RP (Responsible Party's name), but he was not home. I left a message on his voicemail. Addendum 7/1/2012 8:25 am. RP returned my call at 8:30 and was notified of the transfer." These notes were signed by LPN #1. LPN #1 was interviewed on 8/9/12 at 1:35 pm. He stated he noticed Resident #8's toes were blue and cold and she did not have a pedal pulse on Saturday morning, 6/30/12, and called the physician. He said the nurse practitioner (NP) returned the call at 12:00 noon and stated to closely monitor the resident and she would see the resident on the next day she came to the facility, Monday 7/2/12. The LPN stated he passed on the condition of the foot to the next shift (3/11). According to LPN #1, he may have made more assessments of the foot and leg during the shift, but did not document his assessments. The LPN said, "I came in at 6:45 am on 7/1/12, but I did not go to the room to assess the resident. I think she may have been on her way out of the building via regular medical transportation shortly after I came in, but I did make contact with the RP to let him know about the ER transfer." RN #1 was interviewed via telephone on 8/9/12 at 4:00 pm. She stated she received report from LPN #1 on 6/30/12 around 3:00 pm who worked the 7/3 shift regarding problems with the foot; he instructed her to watch the resident. The RN stated toward the end of the shift, she noticed dark colorization creeping up the leg from the toes. She stated the resident would hardly let her touch the leg or foot because of extreme pain. The RN said she did not medicate the resident because the resident only experienced pain when the leg was touched. According to RN#1 she thought the resident was not getting any circulation to the foot and leg and she shared this information with one of unit's managers, Unit Manager LPN #2, who was on the unit at the time. She said she made ongoing assessments of the resident's extremity to include pain issues throughout her assigned shift, but did not document them. RN #1 stated she and the Unit Manager LPN #2 talked about the resident having PVL (a type of arterial blood flow test) studies, but felt the resident could not wait for any scheduled studies and something needed to be done right away. The RN said the physician was called on her shift, but she did not remember exactly what time. She stated, "When I made the call to the physician's service, I spoke to the nurse who screens the calls and I recommended the resident should go out to the ER. I did not think to send the resident to the ER via 911 because (Unit Manager LPN #2's name) was here and we depended on a return call from the doctor." She stated the physician had not called back when she finished her shift; she passed on this information to the 11/7 shift. Unit Manager LPN #2 was interviewed on 8/9/12 at 4:10 pm. She stated she had a habit of showing up on any shift to check out all the residents even though she one of the two unit managers. She checked her time card and discovered she clocked in at 1:59 pm and left at 10:00 pm on 6/30/12. According to the UM, she assessed the resident's foot and leg and shared her assessment and recommendations with RN#1. She stated she told RN#1, "We need to get her out of here; she is too far gone and she cannot wait until Monday for PVL studies." The UM said although she did not document her assessment of the resident's foot and leg; she stated, "You could tell her circulation was impaired. There were no pulses in the leg, the foot and toes were black and the extremity was cold." The UM could not explain why the resident was not sent out via 911 prior to her leaving at 10:00 pm since she had determined from her assessment, the resident's condition was "too far gone." RN #2 was interviewed via telephone on 8/10/12 at 10:00 am. She stated, "(The resident's name) did not look good on the day shift. The 3/11 shift said the leg was worse on her shift and she had placed a call to the physician. When the physician did not call back through my shift (11/7), I made a call to the service around 6:30 am on 7/1/12. I did not want to leave her like that. Her right leg was cold and her toes were black and blue. I didn't think she was going to make it! I really wasn't in charge of the resident that night; the orientee was. I was called in that night to check the all the resident clinical records, medication administration records (MAR) and treatment administration records (TAR) for the end of the month; to make sure everything was done. This is always done at the end of the month. I was considered over the orientee and felt I should do something before we left. I took it on myself to make a call to the physician. I received a response in minutes. I was gone before the resident left the building." RN #2 could not explain why there were no assessments documented of the deteriorating right leg/foot by either her or the orientee. She said she was not sure how many times the orientee assessed the resident throughout the 11/7 shift, but she checked the resident before she left and felt her condition was "grave." She stated there was usually one licensed nurse for the night with 60 residents, but she had been called in to check the end of the month clinical records. On 8/10/12 at 5:00 pm, the Administrator, Interim Director of Nursing (IDON), Assistant Director of Nursing (ADON) stated RN #2 was called in to turn over the end of month records and prepare for the next month. They stated the LPN (#3), assigned to the resident on 6/30/12 11/7, had finished her 7 days orientation and was not considered an orientee. They stated because LPN #3 was not a new nurse, she only required seven days of orientation, which was from 6/20-27/12. LPN #3 was still employed by the facility, but could not be reached for interview. A previous interview was conducted with the Administrator, IDON and ADON on 8/9/12 at 5:05 pm. They stated the facility had a daily Manager on Duty (MOD) system, as well as an RN in the building every shift. They stated if the nurse did not get the physician to call back in a timely manner, they could call the MOD for additional guidance, who assumed that responsibility for 24 hours from 3:00 pm to 3:00 pm the following day. They stated the MOD was not called 6/30/12 on either the 3/11 or 11/7 shift because Unit Manager LPN #2 had been on the unit 6/30/12 3/11 and had already assessed the resident's condition and the staff was waiting for a return call from the physician. When asked if they and the medical director were available for guidance if the physician's answering service did not timely return a call especially in reference to an urgent situation, they responded, "Yes, 24 hours a day." They also said they had personal numbers of physicians, but they usually call back within 10-15 minutes. They stated the documentation was lacking with regard to nursing assessments and in accordance with their facility's policy, they expected ongoing nurse's notes in recognition of a change in condition. There was no evidence of repeated attempts to call the physician and they stated the resident could have been sent out 911. The 24 hour report dated 6/30/12 indicated for the following: "7/3-Toes are turning dark blue. NP and RP aware"; "3/11-recommend send to ER (RN #1's recommendation to the answering service nurse screening calls to the physician) MD notified"; "11/7-toes right foot dark in color, no pedal pulse." During this interview, the IDON stated the resident had a blister on the back of her calf identified on 6/12/12, etiology unknown, and the facility's blister protocol was started. The nurse's note and the Skin Condition Documentation form indicated the intact blister was 3.5 centimeters (cm) by (x) 2.0 cm when identified on 6/12/12 and last documented on 6/26/12 at 3.0 cm x 2.0 cm. They said to their knowledge there were no other areas on the right leg, foot or toes to include pressure areas. The TAR indicated the blister was treated every 7 days, to be discontinued when healed. They could only locate one sheet of the 6/2012 TAR. They stated they were unable to locate TAR's for April, May and the remainder of the 6012. They were also unable to locate physician orders, telephone orders and physician progress notes [REDACTED]. Additionally, they stated the Unit Managers were responsible to conduct weekly skin assessments and complete the assessment forms, but they could not be located and were not made available during the survey. The nurse ' s notes and departmental notes reverted to electronic as of 5/1/12 and were accessed via computer. On 8/10/12 at 12:10 pm, an interview was conducted with Nurse Practitioner (NP). She stated she received a call on the 7/3 shift on 6/30/12 from LPN #1 and told him she would see the resident on the next day she was in the facility. She said she had spoken with the resident's attending physician and it was unfortunate that portions of the chart were unavailable to show whether any prior actions were taken, if any arterial studies were done or ordered, whether the family declined any studies, and; she could not rely on the nurse's notes to give her further assessments or other details, as well as no recent physician/NP progress notes to refer to. She stated the resident had advanced dementia, as well as peripheral artery disease and whether the vessel could have been opened or something else done would be hard to tell based on the resident's history. She stated, "I have been trying to tell the nurse's to document symptoms and stop trying to diagnose a problem. I have had this discussion with them over and over." During the aforementioned interview with the NP a nurse's note dated 6/22/12 was reviewed that indicated the resident's family member inquired about having a follow-up vascular appointment for the right lower leg, and the family would be notified when the appointment was made. The NP stated there may have been a vascular study done, in order to refer the resident to the vascular surgeon, but she was unable to confirm it based on the incomplete clinical record. The NP called her office to have them research whether there were results of a vascular study if one had been done and if a referral to the vascular specialist had also been made. After the NP's inquiry to her office, the only imaging was a chest x-ray on 6/22/12. The Social Worker (SW) joined the interview and stated she was not aware of an order to schedule and provide transportation to the vascular surgeon's office and she coordinated most, if not all, of the resident's appointments. The SW stated most recently on 6/29/12 (Friday), she was approached by Unit Manager LPN #4 (another of the two unit managers) to schedule a follow-up appointment with the vascular surgeon, but it was after office hours. The NP asked the SW why there was a 7 day delay in making the appointment from 6/22/12 to 6/29/12; she stated she would have to do some research. The SW returned on 8/10/12 at 2:35 pm and stated Resident #8's last appointment she made with the vascular surgeon was on January 4, 2012. She added, "I was not made aware of the need to make an appointment prior to 6/29/12. When I came in on Saturday 6/30/12 to deliver items to some of the residents, (Resident #8's daughter's name) approached me and said she was told by Unit Manager LPN #4 I was going to make a follow-up appointment with the vascular surgeon. I told the daughter I was made aware of her request on 6/29/12 after hours, but I would make the appointment on Monday 7/2/12. I was unable to make that appointment because she was transferred to the hospital on Sunday 7/1/12." Unit Manager LPN #4 was interviewed on 8/10/12 at 5:28 pm. She stated, "I was asked by the resident's daughter on 6/22/12 to make an appointment with the vascular surgeon but I can't remember why. I asked the SW on 6/29/12 to make the appointment. She stated, "The only thing I knew about was the blister on the back of her right calf. I was called to the resident's room by the Certified Nursing Assistant (CNA) on 6/12/12 and I initiated that protocol. I saw it at least one more time during a skin assessment. There were no other skin issues. Even though (SW's name) makes most of the appointments, I could have made the appointment myself. As to whether the physician or NP was spoken to about a reason for the appointment or gave me the order, I can't remember. It was one of those 'hit and miss' type of things." The nurse's notes dated 6/22/12 indicated Unit Manager LPN #4 documented the daughter inquired about having a follow-up vascular appointment and she and her brother would be notified when the appointment was made. Resident #8's daughter was interviewed on 8/10/12 at 10:55 am. She stated on 6/22/12, she asked Unit Manager LPN #4 to make an appointment with the vascular surgeon because she felt the resident's leg was painful to touch and it was probably a good time for a follow-up appointment. She said the resident's last appointment in January 2012 did not indicate any problems with the right leg. She said the next time she saw the resident was later in the week between 6/28-30/12 and asked the SW if she was told about the need for an appointment. She stated at that time, she shared with the nurse the resident could not lift her leg, would not let her touch it because of pain, she couldn't move it at all and it looked darker in color. The daughter stated when she arrived at the Emergency Department on 7/1/12, the physician told her she had to be transferred to another hospital for an amputation. She stated all the resident's toes were very dark and shriveled and there were blisters all over the foot and parts of the leg. She stated the physician said the condition of the foot did not happen overnight. She said the resident was transferred to the second hospital in an hour and was told by the physician if they did not amputate, she would die. The right above the knee amputation took place on 7/2/12. The nurse's notes dated 6/22/12, 6/28-30/12 did not document any of the daughter's concerns about the legs. The note at the initial ED indicated the resident arrived on 7/1/12 at 8:52 am. The nurse documented at 9:10 am a large fluid filled sac on dorsal (top) of right foot, nearly covered the entire top of foot. A second was located on the heel approximately 3 x 2 cm and a third fluid filled sac on the right shin (front of leg) 5 cm x 2 cm. The right calf was free of swelling. On 7/1/12 at 9:30 am, the physician at the bedside performed a Doppler (ultrasound test) to the right pedal pulse at the bedside and was unable to assess pulse via the Doppler. At 9:34 am PVL studies were performed which resulted in critical arterial insufficiency in the right lower extremity, absent flow in posterior tibial and dorsalis pedis arteries. Large blister on dorsal right foot from ischemia and ulcers noted on right lower leg, as well as right foot cold to touch especially to toes 2,3,4, and 5. Primary [DIAGNOSES REDACTED]. The vascular specialist at the hospital indicated in a progress note dated 7/1/12 at 10:14 am, the resident had a well perfused foot at the last office visit in January 2012. In addition to the ER MD findings, it was best to perform a right AKA pending vascular evaluation at the second ED where the surgery could be performed. The resident was transported via ambulance to the second ED on 7/1/12 at 10:52 am. This ER physician documented at 11:35 am "Acute vascular insufficiency requiring vascular surgery intervention." Assessment of the leg was consistent with previous assessments: absent DP/PT pulses, cold and large unopened blister on top of the foot. The facility's policy and procedure entitled Routine Resident Care (undated) indicated more than routine care rendered by the licensed staff (according to job description) may include monitoring of unstable or potentially dangerous conditions. COMPLAINT DEFICIENCY

Based on observation, staff interview, facility document review and clinical record review, the facility staff failed to provide and environment free of hazards to prevent accidents for 2 of 17 residents in the survey sample, Residents #2 and #5. Facility staff served coffee at an excessively hot temperature sufficient to cause second and third degree burns to the thighs of Resident #2. Facility staff failed to properly dispose of an insulin syringe. Thesyringe was left on the dinner tray of Resident #5. Findings included: 1. Resident # 2 had second and third degree burns to the thighs as result of spilling hot coffee on her self. The facility staff could not provide evidence of measures were taken to ensure coffee or other hot beverages were served at temperatures that would not cause burns on the residents. Resident #2 was a [AGE] year old admitted to the facility on [DATE]. The residents's current [DIAGNOSES REDACTED]. According to the most recent Annual MDS (Minimum Data Set) assessment , with an ARD (Assessment Reference Date ) of 11/16/10, Resident # 2 was severely impaired, rarely if ever understood, with both short and long range memory problems. Resident # 2 was coded as not demonstrating any behaviors that would put the resident or others at risk. Resident # 2 was coded as totally dependent in eating requiring the assistance of at least one staff member. Review of Resident #2's nurses notes included an entry dated 12/1/10 at 8:35 am which read "This nurse was summon(ed) by aides to observe pt (patient's) legs due to pt dropping coffee on legs. Pt has first degree burn to left upper thigh and 2nd degree to right upper thigh. MD (name of Physician) notified. N.O. (new order) Silvadene cream to areas and wrap with dry dressing q day. RP (Name of Responsible Party) notified. (sign for 'no') distress noted". On 1/6/11 at 2:55pm, CNA #2 stated, on the day of the injury, she was serving a tray and had her back to Resident # 2 when she heard the resident yell "Waffle House, Waffle House". As she turned around she saw the resident spilling a cup of coffee in her lap. She stated it was another resident's coffee. The CNA states she stood Resident # 1 up and "walked her back to her room". She stated she tried to "pull (Resident #1's name) her pants out away from her legs" as they walked. The CNA stated that she "hollered to the nurse" that the resident was burned. Upon arriving at the room the CNA and LPN (Licensed Practical Nurse) # 2 removed the resident's pants to assess the burns. On 1/4/11 at 8:10 am, on 1/5/10 at 8:15 am, and on 1/7/11 at 8:15 am, Resident # 2 was observed in the main dining room being fed. Three other resident's were at the table. None of the resident's at the table had coffee. Review of a consultation report from the Wound Clinic at an Acute Care Facility, dated 12/8/10, where Resident # 2 was being treated for [REDACTED].#2's burns: "Burn to R (right) anterior thigh (with) 12 cm (by) 15 cm (by) 0.1 total area. 20% slough and L (left) medial thigh with 3.5 (by 2.0 (by) 0.1 with 100% pink granular tissue...3rd degree burn healing". Review of the Facility Reported Incident dated 12/03/10, acknowledged "The temperature of the coffee in the kitchen was checked and found to be at 180 degrees" following the injury. The temperature of the coffee served when it reached the dining room at the time of the incident was not measured and cannot be assessed by this surveyor. According to an American Burn Association document entitled Fire and Burn Safety for Older Adults Educator's Guide, under the heading General Background Information ...Risk Factors ...Physical Changes, the document read "Older adults experience a myriad of physical and cognitive changes associated with the aging process that makes them more vulnerable to fire and burn injuries... there are significant changes in sensory perception. The ability to see, hear and feel potential fire and burn dangers diminishes proportionally as one gets older...Since older adults also have thinner skin, they may experience a much deeper burn than a younger person, when exposed to the same amount of flame or other burn injury source.. Under the heading Working with the Older Adult Population, the document continues "With 12.5 % of the population age 65 and older, there is a need to assess and address injury risks affecting them as they age". According to a second document based on the above Burn Association Kit , found at http://www.ameriburn.org/Preven/2000Prevention/Scald2000PrevetionKit.pdf : "The severity of injury with scalds depends on two factors - the temperature to which the skin is exposed and the length of time that the hot liquid is in contact with the skin... When the temperature of a hot liquid is increased to 140o F / 60o C. it takes only five seconds or less for a serious burn to occur. Coffee, tea, hot chocolate and other hot beverages are usually served at 160 to 180o F./ 71-82o C. degrees, resulting in almost instantaneous burns that require surgery to heal". The two factors addressed above are underscored in a Burn Foundation document retrieved from the Internet : Which states "Hot Water Causes a Third Degree Burns ... ...in 1 second at 156? ...in 2 seconds at 149? ...in 5 seconds at 140? ...in 15 seconds at 133?. https://www.burnfoundation.org/programs/resource.cfm?c=1&a=3 On 1/5/11 another surveyor observed the temperature of the coffee poured from the electric coffee urn in the kitchen at 179 degrees. The surveyor returned to the conference room with the coffee and the temperature had reduced to 161 degrees and at five minutes was 155 degrees. On 1/7/11 at 8:15 am this surveyor asked the Assistant Dietary Manager to measure the coffee in the urn in the dining area, which was an unplugged electric urn. The temperature of the coffee was measured at 127 degrees. The surveyor asked the Assistant Dietary Manager to check the temperature of the coffee in the kitchen. The temperature was found to be 167 at the time. The Dietary Manager stated the coffee is transferred from the kitchen urn in a pitcher to an urn in the dining area. She stated that at the time of the injury to resident # 2, the coffee was contained in a non-electric "thermos" type container in the dining room. The Dietary Manager stated, when asked about temperatures of the coffee prior to the injury, the facility was not measuring any coffee temperatures prior to the injury, either in the kitchen or in the serving area. The Dietary Manager was asked for any policy, procedure or guideline for expected temperature of coffee being served. The Manager provided a document, which she stated was what they used, entitled LTC Policy and Procedure : Food Production - Section D (published by the National Purchasing Corp), which read, under the heading Food Holding/ Standard Temperatures "Coffee Trayline Standard 180 to 190 and Bedside standard 160 - 170". Since the injury, the dietary staff have monitored the temperature of the coffee in the kitchen, as part of the facility action plan. From 12/6/10, 5 days following Resident # 1's burn, through 1/3/11, the coffee temperatures ranged from 145 to 187. The average coffee temperature during that time frame was 169 ( breakfast), 166 (lunch) and 155 (dinner). The temperatures at the time of serving are not being monitored. On the morning of 1/5/11 the Director of Nurses (DON) provided a document entitled "Meals -Preparing and Serving" which read under the heading Procedures, item # 4: "Nursing personnel check food for appropriate content , texture and temperature". The DON shared the time line of the event and actions. and a copy of a document entitled Facility Plan of Correction / Action regarding the burn injury to Resident, dated 12/6/10. The document listed the following five actions: 1. Coffee temperature will be monitored by dietary staff. Temps will be within regulatory requirements (Coffee temperatures have been recorded in the kitchen but not in serving area) 2. Staff will pour cups of coffee and set aside until served to residents (observed by surveyor) 3. (Resident's Name) will be placed at a table with non-coffee drinkers (observed by surveyor) 4. Staff will be re-educated on burns and First Aide, Alzheimer's and Dementia (completed 12/6/10) 5. CNA's will be educated on notifying charge nurses immediately if a dressing comes off (completed) Coffee was served at a temperature sufficient to cause second and third degree burns to Resident #2. Prior to the injury, the coffee temperatures were not being taken in the kitchen or the serving area to ensure it was not excessively hot. The facility staff could not provide evidence of measures taken to prevent accidental burns of residents from coffee or other hot beverages. 2. The facility staff failed to properly dispose an insulin syringe of Resident #5 of that was left on the resident's dinner tray. Resident # 5 was a [AGE] year old resident originally admitted 3/31/10 with [DIAGNOSES REDACTED]. The resident also had a [DIAGNOSES REDACTED]. According to Resident #5's latest MDS (Minimum Data Set) Assessment, with an ARD (Assessment Reference Date) of 12/2/10, the resident was coded as moderately impaired in decision making, with both short and long range memory problems. The resident was coded as having no mood or behavior problems. According to the Physician order [REDACTED]. Lantus 100 16 Units at HS (bedtime), Lantus 20 Units in the AM and Novolin R according to a sliding scale order. During the review of a complaint regarding another resident, a picture was observed that indicated an insulin syringe was left on the bedside table of Resident # 5. The picture was labeled "Oct. 21st- Room 114 - ...Syringe left on resident (Name of Resident # 5) table during dinner". In an interview on 1/4/10 with the Administrator and DON (Director of Nursing), the Administrator acknowledged LPN # 9 had left an insulin syringe on the bedside table of Resident # 5, which was brought to the LPN by the son of Resident #5's roommate. The Administrator stated the insulin was administered after dinner. Review of an investigation form provided by the Administrator dated 11/3/10 indicated the LPN had been terminated. COMPLAINT DEFCIENCY