Every finding on record at Dayton Nursing and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to Health and Human Services Commission (HHSC) for 4 of 4 residents (Residents #1, #2, #3 and Resident #4) reviewed for abuse and neglect. 1. The facility did not report allegation of abuse involving Resident #1 and Resident #2 until 19 hours after they were aware of the incident. 2. The facility did not report an allegation of abuse involving Resident #3 until almost 22 hours after they were aware of the incident. 3. The facility did not report an allegation of abuse involving Resident #4 until almost 9 hours after they were aware of the incident. This failure could place residents at risk for further abuse, humiliation, intimidation, fear, shame, agitation, and a decreased quality of life.Findings included: 1. Record review of a face sheet dated 05/28/26 indicated Resident #1 was a [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), generalized anxiety disorder (persistent and excessive worry that interferes with daily activities), and post-traumatic stress disorder (a mental health condition triggered by a terrifying event-either experiencing it or witnessing it). The face sheet indicated Resident #1 discharged to an out-of-town psychiatric hospital on [DATE]. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #1 had a BIMS of 6 out of 15 indicating severely impaired cognition; had no behaviors; supervision or touching assistance for transfers and independent with propelling self in a wheelchair; active diagnoses of Alzheimer's disease, anxiety disorder, and post-traumatic stress disorder; and received an antidepressant medication. Record review of a face sheet dated 05/28/26 indicated Resident #2 was a [AGE] year-old male admitted on [DATE]. His diagnoses included Alzheimer's disease (progressive disease that destroys memory and other important mental functions), bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), mood disorder (mental disorders that primarily affect a person's emotional state), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and generalized anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #2 had a BIMS of 15 out of 15 indicating intact cognition; had no behaviors; required partial/moderate assistance with transfers; had active diagnoses of Alzheimer's disease, bipolar disorder, mood disorder, major depressive disorder, and generalized anxiety disorder; and received antipsychotic medication, antianxiety medication, and antidepressant medication. During an observation and interview on 05/28/26 at 10:38 a.m. Resident #2 was in bed. He was clean, neat, and had no odors. He said he was doing good. He said he liked the facility and had no issues with any staff. Resident #2 said he had an issue with a resident coming into his room several months ago, but he has had no other issues with any resident; he said he felt safe at the facility. Record review of the Provider Investigation Report dated 09/26/25 indicated the incident involving Resident #1 and Resident #2 occurred on 09/22/25 at 06:50 p.m., incident category was Abuse, and it was reported to HHSC on 09/23/25 at 02:00 p.m. Review of the HHSC TULIP Portal indicated the facility was aware of the incident involving Resident #1 and Resident #2 on 09/22/25 at 07:00 p.m.; it was categorized by the facility as Abuse; and it was received in the TULIP Portal on 09/23/25 at 02:41 p.m.-19 hours and 41 minutes after they were aware. 2. Record review of a face sheet dated 05/28/26 indicated Resident #3 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life), and generalized anxiety disorder (persistent and excessive worry that interferes with daily activities). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #3 had a BIMS of 7 out of 15 indicating severely impaired cognition; she had no behaviors; she required supervision or touching assistance with transfers; she had active diagnoses of bipolar disorder, major depressive disorder, and generalized anxiety disorder; and she received antipsychotic medication, antianxiety medication, and antidepressant medication. During an observation and interview on 05/28/26 at 11:00 a.m., Resident #3 was sitting on the side of her bed; she was clean, neat, and had no odors. Interactions with other residents and staff were appropriate. She said she was doing fine, she felt safe with the staff taking care of her, and had no issues. Record review of the Provider Investigation Report dated 01/20/26 indicated the incident involving Resident #3 occurred on 01/15/26 at 02:00 p.m., incident category was Abuse, and it was reported to HHSC on 01/16/26 at 11:50 a.m. Review of the HHSC TULIP Portal indicated the facility was aware of the incident involving Resident #3 on 01/15/26 at 02:00 p.m.; it was categorized by the facility as Abuse and Neglect; and it was received in the TULIP Portal on 01/16/26 at 11:56 a.m.-21 hours and 56 minutes after they were aware. 3. Record review of a face sheet dated 05/28/26 indicated Resident #4 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included dementia (loss of cognitive functioning). Record review of an admission MDS assessment dated [DATE] indicated Resident #4 had a BIMS of 11 out of 15 indicating moderately impaired cognition; she had no behaviors; she required substantial/maximal assistance with transfers; she had active diagnoses of non-Alzheimer's dementia; and she received antidepressant medication. During an observation and interview on 05/28/26 at 11:20 a.m. Resident #4 was up in her wheelchair propelling herself through the facility. She was clean, neat, and had no odors. Interactions with other residents and staff were appropriate. She said she was doing fine, she did not hate anyone. Resident #4 said she had an issue with a nurse recently but it was taken care of, she felt safe with the staff taking care of her, and had no issues. Record review of the Provider Investigation Report dated 05/06/26 indicated the incident involving Resident #4 occurred on 05/01/26 at 07:30 p.m., incident category was Abuse, and it was reported to HHSC on 05/01/26 with no time filled in. Review of the HHSC TULIP Portal indicated the facility was aware of the incident involving Resident #4 on 05/01/26 at 11:30 a.m.; it was categorized by the facility as Abuse and Neglect; and it was received in the TULIP Portal on 05/01/26 at 08:14 p.m.-8 hours and 44 minutes after they were aware. Record review of the Abuse, Neglect, and Exploitation Policy dated 2025 indicated: .VII. Reporting/ResponseA. 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, orb. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. During an interview on 05/28/26 at 03:20 p.m. the Administrator said she was the AC. She said she had received training on ANE. She said she thought if the Abuse did not cause serious bodily injury, then it was to be reported within 24 hours. She said she missed the part on the Provider Letter and the policy that Abuse was to be reported within 2 hours whether there was serious bodily injury or not.

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 15 Residents (Resident #15) who were reviewed for pain management. The facility failed to ensure the WCN assessed for pain and medicated Resident #15 with PRN pain medication prior to wound care and then failed to stop wound care when Resident #15 yelled out in pain multiple times. This failure could place residents who received wound care, who had chronic pain conditions, who received as needed pain medication, or who received routine pain medications at risk for not having their pain addressed causing undue suffering.The findings included: Record review of a face sheet dated 09/17/25 indicated Resident #15 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, osteoporosis (disease that weakens bones) with current pathological fracture and diabetes (too much sugar in the blood). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS score of 99 and was unable to complete the BIMS. Resident #15 had memory problems with short term and long term memories. The MDS indicated the number of unstageable pressure ulcers due to coverage of wound bed by slough (yellow or white tissue with dead cells) and/or eschar (black dead tissue) was 1 and indicated no other pressure ulcers. Record review of the care plan dated 09/12/25 indicated Resident #15 had an actual wound measuring 1.4 cm x 1.1cm x 0.1cm. Medical device pressure stage 4 wound to the left lateral malleolus (ankle) 1.3 cm x 1.4 cm x 0.2 also and the left great toe plantar side (under side of the toe) 2.1 cm x 2. 1cm x UTD area is not open as of 09/11/25. Interventions included Treat as ordered by wound doctor, daily dressing change by nursing, and weekly skin checks. Record review of the physician's orders dated September 2025 indicated Resident #15 had treatments of Wound left lateral malleolus: clean with wound cleaner or NS apply medical honey to wound bed, cover with alginate, paint peri-wound with betadine and cover with dry dressing daily with start date 09/04/25. Wound plantar side left great toe -- clean area with wound cleaner or NS paint with betadine apply betadine-soaked gauze to wound bed and cover with dry dressing daily with start date 09/04/25. Left heel: paint with betadine and leave open to air daily with start date 09/02/25. Resident #15 had orders which included acetaminophen-codeine tablet; 300-30 mg, 1 tablet at bedtime and as needed every 8 hours for pain. Record review of the progress notes in the electronic medical record dated 08/28/25 indicated Resident #15 had 2 new unstageable wounds that were covered by the cast. The wound doctor identified these medical device pressure ulcers and are unstageable at this time. Wound #1 left lateral malleolus 4cm x 4cm x <0.1cm wound bed has 50% slough (yellow or white tissue consisted of dead cells), 50% granulation (new tissue), mild serous exudate (drainage) noted, peri-wound (around the wound) intact. Notified wound doctor received new orders clean with wound cleaner or normal saline, paint peri-wound with betadine, cover wound bed with medical - honey, apply calcium alginate and cover with dry dressing daily and PRN.Wound #2 -- Left great toe plantar side clean with wound cleaner or normal saline, paint with betadine daily cover with dry dressing monitor for area opening. The wound measured 2.0cm x1.5cm area is not open at this time and was unstageable with eschar (dead skin). During an observation and interview on 09/16/25 at 10:15 a.m., observed WCN was preparing to perform wound care to Resident #15. She donned gown and gloves and said Resident #15 was in EBP. She went into the room and prepared the resident for wound care providing privacy, and she spoke Spanish to Resident #15. #1 The WCN performed wound care for the area on coccyx (at the end of the spine). She cleaned the coccyx wound with wound cleanser and painted around the wound with betadine and applied collagen to the wound bed, covered with dry dressing. She performed as needed glove change and hand sanitization for Resident #15 wound on her coccyx. The WCN was removing the boot (a medical device to prevent pressure ulcer and prevent the ankle from moving) and Resident #15 hollered out Oh and Wound Care nurse was still trying to remove the boot. The WCN said she never cries out like this. Resident #15 was grimacing and moaned out, Surveyor asked the ADON to ask her if she was in pain and the resident said her pain was so, so. The WCN removed the boot off. #2. Resident #15 relaxed while the WCN removed her gloves and cleaned her hands with sanitizer and applied new gloves and removed the dressing to the ankle wound and removed gloves, hand sanitizer then donned new gloves. She cleaned the wound from inside out with the wound cleanser. She removed her gloves and donned new gloves without hand sanitizer, applied medical honey to wound bed, covered with alginate, painted peri-wound with betadine and covered with dry dressing. #3 The WCN changed gloves with no hand hygiene performed and applied new gloves. Then she went to remove the dressing on the left great toe, and Resident #15 began to holler out again. The WCN said Resident #15 does not normally have pain like this. The WCN said the pain is new, and she kept performing wound care. When the WCN removed Resident #15 dressing to left toe, Resident #15 quit crying out and relaxed., WCN changed her gloves with no hand hygiene and donned new gloves, cleaned the wound with wound cleanser and applied betadine-soaked gauze and covered with dry dressing the underside of the left great toe. Resident #15 yelled out again when new dressing was applied to great left toe. During an interview on 9/16/25 at 10:40 a.m., the WCN said she should have stopped and medicated the resident for pain. The WCN said she just got nervous and her yelling out was very different. She said normally the resident just doesn't like to be turned. During an interview on 9/17/25 at 8:33 a.m., the DON said WCN should have stopped the treatment and medicated Resident #15 to prevent pain. Record review of the facility's policy Pain - Clinical Protocol' indicated . 5. The nursing staff will identify any situation or interventions where an increase in the resident's pain may be anticipated, for example, wound care .

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic medications (is a medication used: without adequate indication for its use) for 2 of 8 residents (Residents #1 and #37) reviewed for unnecessary medications.* The facility did not have appropriate diagnoses for Resident #1's Risperdal (antipsychotic) and bupropion (antidepressant) and #37. * The facility did not have appropriate diagnoses for Resident #37's duloxetine (antidepressant). This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication.Findings included: 1. Record review of a face sheet dated 09/15/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), chronic obstructive pulmonary disease ((COPD) a lung disease that blocks airflow making it difficult to breathe), depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent and excessive worry that interferes with daily activities), malaise, and herpes viral infection (a viral infection caused by the herpes simplex virus). Record review of September 2025 physician orders indicated Resident #1 had the following medications with no indications for use:* Risperdal (risperidone) 1 mg daily at bedtime; and* bupropion 100mg daily. 2. Record review of physician orders for September 2025 indicated Resident #37 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), atherosclerotic heart disease of native coronary artery (a condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), atrial fibrillation (a type of irregular heartbeat), fracture of head of left femur (broken bone of the left upper leg), chronic kidney disease stage 3 (a disease or condition impairs kidney function, causing kidney damage), intestinal obstruction (a blockage that prevents food or liquid from passing through the small or large intestine), chronic pain, hypertension (a condition in which the force of the blood against the artery walls is too high), anxiety disorder (persistent and excessive worry that interferes with daily activities), and osteomyelitis (an infection in a bone). Record review of September 2025 physician orders indicated Resident #5 had duloxetine 30 mg daily with no indications for use. During a record review and interview on 09/17/25 at 04:00 p.m. LVN C acknowledged the orders were missing diagnoses for the medications on Residents #1 and # 37's orders. She said it was the CN responsibility to put the diagnoses with the psychotropic medications. During an interview on 09/17/25 at 04:10 p.m. the DON and the Administrator said they expected the diagnoses to be placed on the orders when they are written. A policy regarding indication for use for medications was requested on 09/17/25 at 04:15 p.m. from the Administrator but was not provided before exit.

Based on observation, interview and record review, the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen and 6 of 18 residents (#3 #5, #8, and 3 de-identified residents) reviewed for palatable food. The facility failed to provide meal services in a manner to ensure food served was appetizing to residents for 1 of 2 meals observed for palatability and for Residents #3 #5, #8, and 3 de-identified residents. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life. Findings include: During an interview on 09/15/25 at 9:00 a.m., Resident #8 said the food at the facility was not good. He said he preferred not to eat at the facility. He said he kept snacks in his room so he could get enough to eat. He said the meat was always over cooked, dry and tough. Record review of the facility's Weekly Menu dated Spring/ Summer 2025, indicated . [NAME] Sugar Glazed Ham, Butter Beans, Spinach with cheese, corn bread and marshmallow brownie. During an observation and interview on 09/15/25 at 12:30 p.m., revealed Residents #3 and Resident #5 were sitting at a table in the dining room. Resident #5 backed away from the table, leaving his tray which included a whole piece of ham. Resident #5 said the ham was not good and he could not eat it. He said, none of it was good and he left the dining room. His tray still had a serving of spinach with cheese, a serving of butter beans and a whole slice of ham. Resident #3 picked up her ham with her hands. Her tray had untouched portions of the spinach with cheese and the serving of butter beans. Resident #3 put the slice of ham up to her mouth and attempted to bite on it. She did not bite it and placed it back on her tray. She said none of the food was good and the ham was too tough to bite it. She placed her napkin on the tray and backed away. She said she did not want anything else to eat and sat at the table. During observations of the lunch meal on 09/15/25 at 12:45 p.m., 6 unnamed residents did not eat the ham on the tray, and the ham appeared to be dry and over cooked. During the confidential interview with 3 anonymous residents on 09/16/25, they said the ham served at lunch on 09/15/25 was dry, hard, overcooked, very hard to chew, and almost inedible. They said most of the meats served at the facility were overcooked and hard to chew, and they did not eat them. During an interview on 09/16/25 at 2:00 p.m., the DM said no one complained to her on Monday (09/15/25) about the meat being tough. She said the facility had been trying to adjust the menu to the residents' likes and dislikes. She said she observed the cook preparing the ham and he covered it with aluminum foil to preserve the moisture in the meat. She said the facility had been thinking of changing food providers. During an interview on 09/16/25 at 3:16 p.m., the Administrator said the DM had started on Monday (09/15/25). She said the facility had been thinking of developing a resident council team just to work on the food. Record review of the Food and Nutritional Services dated October 2017 indicated Each resident is provided with a nourishing, palatable, well - balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use) for 4 of 8 residents (Residents #1, # 3, #5, and #37) reviewed for unnecessary medications. * The facility did not have appropriate diagnoses for medication for Residents #1, #3, #5, and #37. This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication. Findings included: 1. Record review of a face sheet dated 09/15/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included bipolar disorder (mental disorder associated with episodes of mood swings ranging from depressive lows to manic highs), chronic obstructive pulmonary disease ((COPD) a lung disease that blocks airflow making it difficult to breathe), depression (mental illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent and excessive worry that interferes with daily activities), malaise, and herpes viral infection (a viral infection caused by the herpes simplex virus). Record review of September 2025 physician orders indicated Resident #1 had the following medications with no indications for use:* Anoro Ellipta 62.5-25 mcg/actuation daily at bed time;* lidocaine adhesive patch 4% to right knee twice daily;* Mucinex 600mg twice daily;* omeprazole 40mg daily;* potassium 10 mEq daily;* allopurinol 200 mg daily; and* montelukast 10 mg daily. 2. Record review of a face sheet dated 09/16/25 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included osteomyelitis (an infection in a bone) of the right ankle and foot, peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), atrial fibrillation (a type of irregular heartbeat), systolic congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak), cirrhosis of liver (a condition in which healthy tissue is replaced with scar tissue), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Record review of September 2025 physician orders indicated Resident #3 had the following medications with no indications for use:* Docusate sodium 100 mg twice daily;* Tradjenta 5 mg daily;* amiodarone 200 mg twice daily;* melatonin 15 mg daily at bed time;* hydrocodone-acetaminophen 5-325 mg every 6 hours;* methocarbamol 500 mg three times daily;* Eliquis 5 mg twice daily;* furosemide 40 mg daily;* levothyroxine 175 mcg daily;* meloxicam 15 mg daily;* metoprolol succinate 100 mg daily;* Miralax 17 gm daily; and* omeprazole 20 mg daily. 3. Record review of physician orders for September 2025 indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own), centrilobular emphysema (progressive lung disease primarily caused by smoking, affecting the upper lobes of the lungs and leading to breathing difficulties), peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), seasonal allergic rhinitis (reaction that causes sneezing, congestion, itchy nose and watery eyes), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Record review of September 2025 physician orders indicated Resident #5 had the following medications with no indications for use for acidophilus (lactobacillus acidophilus) daily; and loratadine 10mg daily. 4. Record review of physician orders for September 2025 indicated Resident #37 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included type 2 diabetes (a chronic condition that affects the way the body processes blood sugar), atherosclerotic heart disease of native coronary artery (a condition where the blood vessels become narrowed and hardened due to buildup of fats in the blood vessel wall), atrial fibrillation (a type of irregular heartbeat), fracture of head of left femur (broken bone of the left upper leg), chronic kidney disease stage 3 (a disease or condition impairs kidney function, causing kidney damage), intestinal obstruction (a blockage that prevents food or liquid from passing through the small or large intestine), chronic pain, hypertension (a condition in which the force of the blood against the artery walls is too high), anxiety disorder (persistent and excessive worry that interferes with daily activities), and osteomyelitis (an infection in a bone). Record review of September 2025 physician orders indicated Resident #5 had the following medications with no indications for use:* Admelog Units-100 insulin lispro with meals;* Adult low dose aspirin 81 mg daily;* gabapentin 100 mg every 8 hours;* methocarbamol 500 mg four times daily;* metoprolol succinate 50 mg daily;* atorvastatin 40 mg daily at bed time;* losartan 50 mg daily;* meloxicam 7.5 mg daily; and* omeprazole 20 mg daily. During a record review and interview on 09/17/25 at 04:00 p.m. LVN C acknowledged the orders were missing diagnoses for the medications on Residents #1, #3, #5, and # 37's orders. She said it was the CN responsibility to put the diagnoses with the medications. During an interview on 09/17/25 at 04:10 p.m. the DON and the Administrator said they expected the diagnoses to be placed on the orders when they are written.

Based on observation, record review, and interviews, the facility failed to ensure residents received food prepared in a form designed to meet individual needs for 1 of 2 meals, reviewed for nutrition services. The facility failed to ensure the lunch meal served on 09/16/25 had the appropriate consistency for the meat and au gratin potatoes serving for the pureed textured diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss.The findings included: During an observation on 09/16/25 at 12:00 p.m. revealed [NAME] D prepared the pureed pot roast turkey for the residents. [NAME] D pureed the au gratin potatoes and said there were 4 residents on a pureed diet. During an observation and interview on 09/16/25 at 12:40 p.m., revealed the test tray for the pureed diet consisted of pot roast turkey, au gratin potatoes and a vegetable melody. The pot roast turkey had small bits and was not smooth. The au gratin potatoes had small size pieces of potatoes. [NAME] D said he should have let the meat and potatoes run longer in the food processor. He said the pureed diet should be smooth and a pudding consistency to prevent choking. During an interview on 09/16/25 at 12:43 p.m. the DM said the facility had 4 residents who received pureed diets. She said the pureed food should not have lumps and should be smooth. Record review of the facility's Therapeutic Diets dated October 2017 indicated Therapeutic diets are prescribed by the attending physician to support the resident's treatment and plan of care in accordance with his or her goals and preferences. Policy Interpretation and Implementation . 5. If a mechanically altered diet is ordered, the provider will specify the texture modification.Record review of a reference obtained on the internet at Microsoft Word - 4_Pureed_p2_Adults_food to AVOID page_consumer handout_30Jan2019.docx indicated . What is this food texture level? Level 4 - Pureed Foods: Are usually eaten with a spoonDo not require chewing. Have a smooth texture with no lumps.

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen, 1 of 2 refrigerator, 2 of 5 walls, and the dishwasher reviewed for food served under sanitary conditions. The facility failed to ensure sandwiches were dated and labeled in 1 of 2 refrigerators. The facility failed ensure the 2 of 5 walls were free of black streaks of an unknown substance. The facility failed to ensure the dishwasher was maintained with sanitizer level at 50ppm. These failures could place residents at risk for food contamination, food borne illness and a diminished quality of life.The findings included: During an observation on 09/15/25 at 8:00 a.m., revealed the dish machine was ran 3 times and reached a temperature of 120 degrees Fahrenheit by Dietary Aide B. The dishwasher was run for a fourth time and the Dietary Aide B put the test strip in the water and there was no color change. She tried again and still no color change. She said she had not been trained on what to do if the dish machine did not have sanitation chemicals. She looked at the manufacturer signage posted on the dish machine which indicated the sanitization chemical level should be 50 ppm. After the surveyor intervened asked for the DM. During the observations and interviews on 09/15/25 at 8:20 a.m., the refrigerator contained 3 sandwiches without labels or dates. Dietary Aide B said the 3 sandwiches had no date of when the sandwiches were placed in the refrigerator. During an observation and interview on 09/15/25 at 8:30 a.m., revealed the DM came in the dish machine room and had brought new test strips. She ran the dish machine and checked the sanitization level and again no color change. She attempted to manually get the chemicals to enter the machine with a prime switch on the side of the machine. She rechecked the chemicals and said the dietary will use the 3-compartment sink and paper goods until the repair company fixed the dish machine, and she said maintenance would fix the back left burner. During an observation and interview on 09/15/25 at 9:00 a.m., indicated under the 3-compartment sink on the wall were 3 streaks of a black substance approximately 4 inches by 5 inches; and under the drying area from the dish machine, there were 2 streaks of black substance approximately 3 inches by 4 inches. During an interview on 09/16/25 at 11:00 a.m., the DM said the areas should be clean and free of discolored areas. She said all items in the refrigerators should be labeled and dated to prevent food borne illness. She said the walls should be deep cleaned weekly in those areas. Record review of facility's Food Receiving and Storage dated November 2022 indicated . Food services, or other designated staff, maintain clean. 7. Refrigerated foods are labeled, dated and monitored so they are used be the use-by date, frozen or discarded.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 15 residents reviewed for infection control. (Residents #3, #4, & #15) 1. The facility failed to ensure the WCN performed proper hand hygiene every time she changed gloves during wound care for Resident #3. 2. The facility failed to ensure the Wound Care Nurse performed proper hand hygiene and used a clean applicator for each separated area of the wound during wound care for Resident #4. 3. The facility failed to ensure the Wound Care Nurse performed proper hand hygiene every time she changed gloves during wound care for Resident #15. These failures could place residents at risk for cross contamination and the spread of infection.1. Record review of a face sheet dated 09/16/25 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included osteomyelitis (an infection in a bone) of the right ankle and foot, peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), atrial fibrillation (a type of irregular heartbeat), systolic congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak), cirrhosis of liver (a condition in which healthy tissue is replaced with scar tissue), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). Record review of the quarterly MDS dated [DATE] indicated Resident #3 had minimal difficulty hearing, he had clear speech, and he was able to make himself understood and understood others. He had 2 arterial and venous ulcers. Record review of September 2025 physician's orders for Resident #3 indicated the following orders: * 08/18/2025 Wound --Left third toe--Clean with wound cleaner or NS, cover with silver alginate and dry dressing 3 times weekly M-W-F; * 08/18/2025 Wound--Left 2nd toe--Clean with wound cleaner or NS apply alginate with silver and cover with dry dressing 3 times weekly M-W-F; * 08/18/2025 Wound: Right third toe -- clean with wound cleaner or NS pat dry apply calcium alginate with silver and cover with band aid 3 times weekly M-W-F; * 09/03/2025 Wound -- Left distal (the distance of a body part from a reference point) lateral (the side of the body on which a body part is located) ankle - Clean with wound cleaner or NS, silver alginate to wound bed cover with absorbent pad wrap with [NAME] boot (a compression dressing made by wrapping layers of gauze around your leg and foot), stretch gauze and wrap with cohesive bandage 3 times weekly M-W-F; * 09/05/2025 Wound -- Traumatic left calf -- Clean with wound cleaner apply silver alginate, cover and secure with [NAME] boot, stretch gauze and cohesive bandage 3 times weekly M-W-F; * 09/15/2025 Wound--Right anterior (front or forward-facing part of the body) lower leg-- Clean with wound cleaner or NS, apply alginate with silver to wound bed, cover with absorbent pad, wrap with [NAME] boot, stretch gauze and cohesive dressing 3 times weekly M-W-F; and * 09/15/2025 Wound--right lateral lower leg -- clean with wound cleaner or NS, apply alginate with silver to wound bed, cover with absorbent pad, wrap with [NAME] boot, stretch gauze and cohesive dressing 3 times weekly M-W-F. Record review of a Care Plan initiated 01/26/23 and edited on 09/15/25 indicated Resident #3 was at risk for impaired skin integrity related to CHF, chronic venous hypertension, CAD, decreased mobility. Resident #3 has actual wounds--diabetic ulcer (wound that is a complication of diabetes) left toe 1.5cm x 1.0cm x 0.1cm, a vascular ulcer (wounds that develop because of problems with blood circulation) right lateral lower leg 3.1cm x 2.5cm x 0.2cm, a vascular ulcer right anterior lower leg 18cm x 9.5cm x 0.2cm ,a vascular ulcer lower left lateral ankle 0.5cm x 0.4cm x 0.1cm, a diabetic ulcer left second toe 0.3cm x 0.2cm x 0.1cm, and a diabetic ulcer right plantar (related to the sole of the foot) toe 0.3cm x 0.2cm x 0.2cm. During an observation and interview on 09/15/25 at 10:45 a.m., the WCN did not wash her hands when she entered the resident's room and did not sanitize her hands twice when changing gloves, after cleaning the wound and prior to putting the silver alginate on the wounds to the left leg. After she finished the treatment to the left leg she did not wash her hands before donning (putting on) clean gloves to perform wound care to the right leg. She did not sanitize her hands twice when changing gloves, after cleaning the wound and prior to putting the silver alginate on the wounds to the right leg. When the WCN was asked if there was anything she could have or should have done differently, she said she probably should have changed her gloves more often and sanitized her hands between some of the glove changes she missed. 2. Record review of a face sheet dated 09/17/25 indicated Resident #4 was a [AGE] year-old-female readmitted on [DATE] with a diagnoses of pressure ulcer (a localized area of skin damage that develops when prolonged pressure is applied to the body), history of malignant (cancerous) neoplasm (tumor) of colon, and skin changes due to chronic exposure to radiation (a cancer treatment that uses high-energy rays to damage and kill cancer cells). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #4 had a BIMS score of 15 indicating her cognition was intact, required substantial/maximal assistance with bed mobility, and had a stage 4 pressure ulcer. Record review of a physician's order for Resident #4 dated 08/15/25 indicated to clean the wound to the coccyx with wound cleanser, apply betadine to peri wound, apply wound gel to wound bed, apply collagen to wound bed, and cover with dry dressing daily and as needed. Record review of a care plan with last revised 09/05/25 indicated Resident #4 had a pressure ulcer related to impaired mobility, stage 4 (a severe form of pressure injury that involves full-thickness tissue loss, exposing bone, tendon, or muscle), to her coccyx. The long-term goal was that the resident's ulcer would not increase in size and not exhibit signs of infection. During an observation and interview on 09/15/25 at 9:20 a.m., Resident #4 was sitting in her bed knitting. She said she had a wound to her buttocks that started from radiation when she had anal cancer. She said she had a colostomy (a surgical procedure that creates and opening (stoma) in the abdominal wall to divert stool from the colon (large intestine) to an external pouch) and a suprapubic catheter (a thin, flexible tube inserted through a small incision in the lower abdomen to drain urine from the bladder). During an observation and interview on 09/16/25 at 9:00 a.m., the Wound Care Nurse gowned outside the room and entered without gloves. She adjusted the privacy curtain and donned gloves without washing or sanitizing her hands. She assisted Resident #4 to roll to her left side. The Wound Care Nurse changed her gloves without performing hand hygiene. Resident #4 had 3 visible wounds which included a sacral wound approximately fist size had a pink wound bed, a wound to her right leg was approximately dime size with a pink wound bed at the right lower buttock crease and another wound to the right leg approximately nickel size with a pink wound bed. The Wound Care Nurse said all three wounds were part of the original coccyx wound, and the areas opened and closed frequently. Surrounding the wounds was redness extending to the left buttocks and down the right leg. The Wound Care Nurse cleansed each wound with a wound cleanser and patted them dry with gauze. The Wound Care Nurse then performed hand hygiene and changed gloves. She then applied wound gel to each wound using the same wooden spoon. She applied collagen to each wound. She covered each wound with a dry dressing. She then applied betadine to all reddened areas surrounding the wound and left resident on her left side with a fan on to dry the betadine. She said the betadine would sit for 30 minutes with the fan blowing the area. During an observation at 09/16/25 at 9:40 a.m., the Wound Care Nurse sanitized her hands, gowned and gloved and turned off the fan and repositioned the Resident #4 for comfort. During an interview on 09/17/25 at 4:20 p.m., the Wound Care Nurse said that during Resident #4's wound care she should not have used the same wooden spoon to apply wound gel to her 3 sperate open areas. She said she should have washed her hands or performed hand hygiene with glove changes. She said she had been the Wound Care Nurse at the facility for 1 year and had gotten her wound care certification 2 years ago. She said she also received additional training every week from the wound care doctor. She said the possible negative outcome for not performing hand hygiene and using the same wooden spoon to apply wound gel to all three separate areas of the wound could be cross contamination of the wounds and increased exposure to possible infection. During an interview on 09/17/25 at 4:20 p.m. the DON said he expected all nurses to follow facility policy and protocol regarding infection control. He said the Wound Care Nurse should perform hand hygiene with all glove changes and use a new utensil to apply wound gel to each wound. He said the possible result on not observing infection control protocol could be cross contamination of the wounds and increased risk of wound infections. 3. Record review of a face sheet dated 09/17/25 indicated Resident #15 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, osteoporosis (disease that weakens bones) with current pathological fracture (fracture could be caused by disease process and diabetes (too much sugar in the blood). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS score of 99 and was unable to complete the BIMS. Resident #15 had memory problems with short term and long-term memories. The MDS indicated the number of unstageable pressure ulcers due to coverage of wound bed by slough (yellow or white tissue contained dead cells) and/or eschar (black tissue dead cells) was 1 and indicated no other pressure ulcers. Record review of the care plan dated 09/12/25 indicated Resident #15 had an actual wound measuring 1.4 cm x 1.1cm x 0.1cm. caused by a medical device pressure stage 4 wound to the left lateral malleolus (ankle) 1.3 cm x 1.4 cm x 0.2 also and the left great toe plantar side (under side of the toe) 2.1 cm x 2. 1cm x UTD area is not open as of 09/11/25. Interventions included to treat as ordered by the wound doctor, daily dressing change by nursing, and weekly skin checks. Record review of the physician's orders September 2025 indicated Resident #15 had treatments for a wound to the left lateral malleolus (ankle): clean with wound cleaner or NS apply medical honey to wound bed, cover with alginate, paint peri-wound with betadine and cover with dry dressing daily with start date 09/04/25. A wound on the plantar side (underside) left great toe: clean area with wound cleaner or NS paint with betadine apply betadine-soaked gauze to wound bed and cover with dry dressing daily with start date 09/04/25. The left heel: paint with betadine and leave open to air daily with start date 09/02/25. Record review of the progress notes in the electronic medical record dated 08/28/25 indicated Resident #15 had 2 new unstageable wounds that were covered by the cast. The wound doctor identified these medical device pressure ulcers and were unstageable at this time. Wound #1: left lateral malleolus 4cm x 4cm x <0.1cm wound bed has 50% slough (yellow or white consists of dead cells), 50% granulation (new tissue), mild serous exudate (drainage) noted, peri-wound (around the wound) intact. The nurse notified the wound doctor and received new orders to clean with wound cleaner or normal saline, paint peri-wound with betadine, cover the wound bed with medical - honey, apply calcium alginate and cover with a dry dressing daily and PRN. Wound #2: the left great toe plantar side (the underside) , clean with wound cleaner or normal saline, paint with betadine daily and cover with dry dressing monitor for area opening. The wound measured 2.0cm x1.5cm area and was not open at this time. The wound was unstageable with eschar (dead skin). During an observation and interview on 09/16/25 at 10:15 a.m., the Wound Care Nurse was preparing to perform wound care for Resident #15. She donned a gown and gloves and said Resident #15 was on EBP. She went into the room and prepared the resident for wound care, providing privacy and she spoke Spanish to Resident #15. #1 The Wound Care Nurse cleaned Resident #15's coccyx with wound cleaner or NS paint peri-wound with betadine, applied collagen to the wound, and covered with a dry dressing. She performed the needed glove change and hand sanitization. #2. The wound Care Nurse removed her gloves and cleaned her hands with sanitizer and applied new gloves and removed the dressing to Resident #15's ankle wound and removed her gloves, sanitized her hands then donned gloves. She cleaned the wound from inside out with wound cleaner. She removed her gloves and donned new gloves without hand sanitizer. She applied medical honey to the wound bed, covered with alginate, painted the peri-wound with betadine and covered with dry dressing. #3 Then changed gloves no hand hygiene was performed applied new gloves. Then she went to remove the dressing on the left great toe When the Wound Care Nurse removed Resident #15's dressing to her left toe. The Wound care nurse changed her gloves did not perform hand hygiene and donned new gloves. The Wound Care Nurse cleaned the wound with wound cleanser and applied gauze soaked with betadine and covered with a dry dressing. Wound plantar side left great toe -- cleaned area with wound cleaner painted with betadine apply betadine-soaked gauze to wound bed and cover with dry dressing daily. Resident #15 yelled out again when new dressing was applied to great left toe. The Wound Care Nurse removed her gloves and washed her hands and said she had finished wound care. #4 The Wound Care Nurse donned new gloves and painted the back of the left heel with betadine and left open. She removed her gloves and washed her hands. During an interview Wound Care Nurse said she should have used hand sanitizer during each glove change. She said that was to prevent spread of germs and said she just got nervous and Resident #15 yelling out was very different. She said normally Resident #15 just did not liked to be turned. Record review of a facility policy titled, Wound Care revised October 2010 indicated .Steps in the Procedure 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. .4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. . 13. Dress wound. Pick up sponge with paper and apply directly to area. [NAME] tape with initials, time, and date and apply to dressing. 14. Be certain all clean items are on clean field. 15. Remove the disposable cloth next to the resident and discard into the designated container. 16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of a facility policy titled, Handwashing/Hand Hygiene last revised August 2019, indicated, . The facility considers hand hygiene the primary means to prevent the spread of infections. Applying and Removing Gloves: 1. Perform hand hygiene before applying non-sterile gloves. 2. When applying, remove one glove from the dispensing box at a time, touching only the top of the cuff. 3. When removing gloves, pinch the glove at the wrist and peel away from the hand, turning the glove inside out. 4. Hold the removed glove in the gloved hand and remove the other glove by rolling it down the hand and folding it into the first glove. 5. Perform hand hygiene.

Based on observation, interview, and record review the facility failed to treat each resident with respect and dignity for 1 of 4 residents (Resident #3) reviewed for resident rights.* The ADON did not knock on Resident #3's room door prior to entering the room. This failure could place residents at risk for decreased quality of life.Findings included:Record review of a face sheet dated 09/16/25 indicated Resident #3 was a [AGE] year-old male admitted on [DATE]. His diagnoses included osteomyelitis (an infection in a bone) of the right ankle and foot, peripheral vascular disease (blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), atrial fibrillation (a type of irregular heartbeat), systolic congestive heart failure (a condition in which the heart's main pumping chamber (left ventricle) is weak), cirrhosis of liver (a condition in which healthy tissue is replaced with scar tissue), chronic obstructive pulmonary disease (a lung disease that blocks airflow making it difficult to breathe), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar), and Alzheimer's disease (progressive disease that destroys memory and other important mental functions).Record review of the quarterly MDS dated [DATE] indicated Resident #3 had minimal difficulty hearing, he had clear speech, and he was able to make himself understood and understood others.During an observation on 09/15/25 at 10:45 a.m. the WCN was conducting wound care on Resident #3. The door to the room was closed. The ADON opened Resident #3'a door and did not knock prior to opening the door. The WCN had to yell out Patient Care to stop the ADON from entering the room. During an interview on 09/16/25 at 04:35 p.m. the WCN said staff were normally good about knocking on the door prior to opening and entering the resident room. She said she did not know why the ADON did not knock on the door. During an interview on 09/16/25 at 04:45 p.m. the ADON said she thought Resident #3 was in the dining room for an activity. She said she did not realize he was in the room having wound care done. She said staff should always knock on a resident's door before opening and entering the room. She said if the person knocking on the door could not hear the person in the room they should just open the door enough to hear the person in the room. During an interview on 09/17/25 at 02:25 p.m. Resident #3 said staff would sometimes forget to knock on the door before they entered. He said it did not bother him all the time but sometimes it did.During an interview on 09/17/25 at 04:10 p.m. the DON and the Administrator said they expected all staff to knock on the resident door before they entered. A policy related to staff knocking on resident doors was requested on 09/17/25 at 04:15 p.m. from the Administrator but not provided before exit.

Based on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 2 residents reviewed for resident rights. (Resident #5) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #5. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state. Findings included: Record review of physician orders for [DATE] indicated Resident #5 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included respiratory failure (a serious condition that makes it difficult to breathe on your own) and Alzheimer's disease (progressive disease that destroys memory and other important mental functions). An order dated [DATE] indicated Resident #5 had an order for DNR. Record review of a quarterly MDS dated [DATE] indicated Resident #5 had minimal difficulty hearing, she had clear speech, she was able to make herself understood, she was able to understand others, and a BIMS of 4 out of 15 indicating she had severely impaired cognition. Record review of a Care Plan for Resident #5 indicated a care plan for Code Status: DNR with a problem start date of [DATE], a Long Term Goal Target date of [DATE], and edit date of [DATE]. One of the interventions with an Approach Start Date of [DATE] indicated advanced directives would be reviewed by care plan team quarterly and prn. Record review of the OOH-DNR form dated [DATE] for Resident #5 indicated Section A of the form was signed by Resident #5 and Section B of the form was signed by the RP. The bottom of the form indicated All persons who have signed above must sign below, acknowledging that this document has been properly completed. The bottom of the form was not signed by the resident or the RP. During an observation and interview on [DATE] at 10:28 a.m. Resident #5 was sitting up in her wheelchair in her room. She said she was doing fine. She said she did not want anyone doing CPR on her she just wanted to pass peacefully. During an interview on [DATE] at 04:10 p.m. the DON, LVN C, and the Administrator said an incomplete OOH-DNR would mean Resident #5 was a full code (staff would have to initiate CPR). The Administrator said hospice services obtained the DNR on Resident #5 and should have ensured it was complete but ultimately it was the facility's responsibility. The DON said the negative outcome would be the resident could have CPR preformed on them against their wishes. Record review of a Do Not Resuscitate Order policy revised [DATE] indicated: .2. A Do Not Resuscitate (DNR) order form must be completed and signed by the attending physician and resident (or resident's legal surrogate, as permitted by state law) and placed in the front of the resident's medical record.

Based on observation, interview and record review, the facility failed to consult with the resident's physician and notify the representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 15 residents (Resident #15) reviewed for quality of care. The facility failed to notify the WC physician or physician of Resident #15's increase of pain during wound care observed on 09/16/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition. Findings included: Record review of a face sheet dated 09/17/25 indicated Resident #15 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnosis included Alzheimer's disease, osteoporosis (disease that weakens bones) with current pathological fracture and diabetes (too much sugar in the blood). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS score of 99 and was unable to complete the BIMS. Resident #15 had memory problems with short term and long-term memories. The MDS indicated the number of unstageable pressure ulcers due to coverage of wound bed by slough (dead or non-viable tissue) and/or eschar (dead tissue) was 1 and indicated no other pressure ulcers. Record review of the care plan dated 9/12/25 indicated Resident #15 had an actual wound measuring 1.4 cm x 1.1cm x 0.1cm. Medical device pressure stage 4 wound to the left lateral malleolus (ankle) 1.3 cm x 1.4 cm x 0.2 also and the left great toe plantar side (under side of the toe) 2.1 cm x 2. 1cm x UTD area is not open as of 09/11/25. Interventions included Treat as ordered by wound doctor, daily dressing change by nursing, and weekly skin checks. Record review of the physician's orders dated September 2025 indicated Resident #15 had treatments of Wound left lateral malleolus (ankle): clean with wound cleaner or NS apply medical honey to wound bed, cover with alginate, paint peri-wound with betadine and cover with dry dressing daily with start date 09/04/25. Wound plantar side left great toe -- clean area with wound cleaner or NS paint with betadine apply betadine-soaked gauze to wound bed and cover with dry dressing daily with start date 09/04/25. Left heel: paint with betadine and leave open to air daily with start date 09/02/25. The orders included acetaminophen-codeine tablet; 300-30 mg; 1; oral at bedtime; and acetaminophen-codeine tablet; 300-30 mg; 1; oral every 8 hours - as needed. Record review of the progress noted in the electronic medical record dated 08/28/25 indicated Resident #15 had 2 new unstageable wounds that were covered by the cast. The wound doctor identified these medical device pressure ulcers and are unstageable at this time. Wound #1 left lateral malleolus 4cm x 4cm x <0.1cm wound bed has 50% slough (yellow or white tissue consists of dead cells), 50% granulation (new tissue), mild serous exudate (drainage) noted, peri-wound (around the wound) intact. Notified wound doctor received new orders clean with wound cleaner or normal saline, paint peri-wound with betadine, cover wound bed with medical - honey, apply calcium alginate and cover with dry dressing daily and PRN.Wound #2 -- Left great toe plantar side clean with wound cleaner or normal saline, paint with betadine daily cover with dry dressing monitor for area opening. Wound measures 2.0cm x1.5cm area is not open at this time. Unstageable with eschar (dead skin). Record review of nurse notes for 9/16/25 to 9/17/25 reflected no indication of physician or WC physician being notified of increase with Resident #15 pain level. During an observation and interview on 9/16/25 at 10:15 a.m. the WCN was preparing to perform wound care to Resident #15. She donned gown and gloves and said Resident #15 was in EBP. She went into the room and prepared the resident for wound care providing privacy, and she spoke Spanish to Resident #15. #1 The WCN performed wound care for the area on coccyx (the end of the spine). She cleaned the coccyx wound with wound cleanser and painted around the wound with betadine and applied collagen to the wound bed, covered with dry dressing. She performed as needed glove change and hand sanitization for Resident #15 wound on her coccyx. The WCN was removing the boot (a medical device that prevent pressure and prevents movement of the ankle) that covered her left foot and extended up her calf). Resident#15 hollered out Oh and Wound Care nurse was still trying to remove the boot. The WCN said she never cries out like this. Resident #15 was grimacing and moaned out, Surveyor asked the ADON to ask her if she was in pain and the resident said her pain was so, so. The WCN removed the boot off. #2 Resident #15 relaxed while the WCN removed her gloves and cleaned her hands with sanitizer and applied new gloves and removed the dressing to the ankle wound and removed gloves, hand sanitizer then donned new gloves. She cleaned the wound from inside out with the wound cleanser. She removed her gloves and donned new gloves without hand sanitizer,. applied medical honey to wound bed, covered with alginate, painted peri-wound with betadine and covered with dry dressing. #3 The WCN changed gloves with no hand hygiene performed and applied new gloves. Then she went to remove the dressing on the left great toe, and Resident #15 began to holler out again. The WCN said Resident #15 does not normally have pain like this. The WCN said the pain is new, and she kept performing wound care. When the WCN removed Resident #15 dressing to left toe, Resident #15 quit crying out and relaxed., WCN changed her gloves with no hand hygiene and donned new gloves, cleaned the wound with wound cleanser and applied betadine-soaked gauze and covered with dry dressing. Resident #15 yelled out again when new dressing was applied to great left toe. During an interview on 9/16/25 at 10:45 a.m., the WCN said her yelling out was very different. She said normally the resident just doesn't like to be turned. She said she will report changes to the nurse, and she does not call the physician or wound care physician. During an observation on 9/16/25 at 10:50 a.m., the WCN was walking to Resident #15 room and said the charge nurse was going to medicate her for the increased pain. During an interview on 9/17/25 at 7:55 a.m., the Administrator said she spoke to the nursing staff about not stopping the treatment and medicating the residents. The Administrator said the nurses just leave notes for the primary physician to see and when he makes rounds, he would see it. During an interview on 9/17/25 at 8:33 a.m., the DON said WCN had reported an increase in her pain with Resident #15. The DON said the nurses should have called the wound care physician. During an interview on 9/17/25 at 10:28 a.m., the WC physician said he had not been notified of the increase of pain for Resident #15. He said the facility would need to notify him or the primary physician if there was a change in pain level with the residents. He said it could indicate infection or changes in the wound.

Based on observation, interview, and record review, the facility failed to ensure the assessments accurately reflected the resident's status for 2 of 18 residents reviewed for accuracy of assessments. (Residents #13 & #15) 1. The facility failed to ensure Resident #13's most recent quarterly assessment captured the resident's daily Aspirin as an antiplatelet. 2. The facility failed to ensure Resident #15's most recent quarterly assessment captured the current number of unstageable pressure ulcer as 2 unstageable pressure ulcers. These failures could place the residents at risk of not receiving the appropriate care and services. Findings included: 1. Record review of a face sheet dated 09/17/25 indicated Resident #13 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included a history of pulmonary embolism (a condition in which one or more arteries in the lungs become blocked by a blood clot) and dementia (a group of thinking and social symptoms that interfere with daily functioning). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #13 had a BIMS score of 4 indicating she had severely impaired cognition, she was dependent for most ADLs and was taking an anticoagulant medication. Record review of a care plan last revised 08/13/25 indicated Resident #13 was at risk for bleeding and bruising secondary to use of a blood thinning medication. The goal indicated Resident #13 would not have any open areas or uncontrolled bleeding secondary to use of blood thinning medications. Record review of a physician order dated September 2025 indicated Aspirin-enteric coated 81mg 1 tablet orally once a day for diagnosis of ischemic heart disease (damage or disease in the heart's major blood vessels). During an observation on 09/15/25 at 8:48 a.m., Resident #13 was lying in bed with her call light in reach. She was unable to answer questions. During a telephone interview on 09/17/25 at 2:06 p.m., the MDS Nurse said that she started completing MDS assessments for the facility on 08/28/25. She said she used the RAI manual for coding all MDS. She said she was never formally trained on completing MDS but received most of her training in 2013 over the phone with an MDS consultant. She said she did view webinars for updates and changes in MDS and RAI manual. She said she worked remotely and had never actually visited the facility or assessed a facility resident in person. She said she reviewed Resident #13's most recent quarterly assessment and her medications and the MDS was coded incorrectly for anticoagulant because Aspirin was not classified as an anticoagulant it was classified as an antiplatelet. She said the DON was responsible for reviewing her coding in all MDS and correcting before submission to CMS. She said the possible negative outcome of an incorrectly coded MDS could be an inaccurate care plan for the residents. During an interview on 09/17/25 at 4:25 p.m., the DON said the MDS Nurse for the facility was out of the country, so MDS assessments were currently being done remotely. He said he expected MDS to be coded as outlined in the RAI manual. He said he reviewed all MDS and had missed that Aspirin was coded as an anticoagulant when it should have been coded as an antiplatelet for Resident #13. He said he was responsible for reviewing all MDS and approving them. He said he needed to review all MDS more carefully. He said the possible negative outcome of an incorrectly coded MDS could be an inaccurate care plan. During an interview on 09/17/25 at 5:20 p.m., the Administrator said the MDS Nurse, and the DON were responsible for ensuring all MDS were coded correctly. She said the possible negative outcome of incorrect coding of the MDS could be residents not receiving the care they needed. 2. Record review of a face sheet dated 09/17/25 indicated Resident #15 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, osteoporosis (disease that weakens bones) with current pathological fracture and diabetes (too much sugar in the blood). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS score of 99 and was unable to complete the BIMS. Resident #15 had memory problems with short term and long-term memories. The MDS indicated the number of unstageable pressure ulcers due to coverage of wound bed by slough and/or eschar was 1 and indicated no other unstageable pressure ulcers. Record review of the care plan dated 09/12/25 indicated Resident #15 had an actual wound measuring 1.4 cm x 1.1cm x 0.1cm. Medical device pressure stage 4 wound to the left lateral malleolus (ankle) 1.3 cm x 1.4 cm x 0.2 also and the left great toe plantar side (under side of the toe) 2.1 cm x 2. 1cm x UTD area is not open as of 09/11/25. Interventions included Treat as ordered by wound doctor, daily dressing change by nursing, and weekly skin checks. Record review of the physician's orders dated September 2025 indicated Resident #15 had treatments of Wound left lateral malleolus: clean with wound cleaner or NS apply medical honey to wound bed, cover with alginate, paint peri-wound with betadine and cover with dry dressing daily with start date 09/04/25. Wound plantar side left great toe -- clean area with wound cleaner or NS paint with betadine apply betadine-soaked gauze to wound bed and cover with dry dressing daily with start date 09/04/25. Left heel: paint with betadine and leave open to air daily with start date 09/02/25. Record review of the progress noted in the electronic medical record dated 08/28/25 indicated Resident #15 had 2 new unstageable wounds that were covered by the cast. The wound doctor identified these medical device pressure ulcers and are unstageable at this time. Wound #1 left lateral malleolus 4cm x 4cm x <0.1cm wound bed has 50% slough (yellow or white tissue consists of dead cells), 50% granulation (new tissue), mild serous exudate (drainage) noted, peri-wound (around the wound)intact. Notified wound doctor received new orders clean with wound cleaner or normal saline, paint peri-wound with betadine, cover wound bed with medical - honey, apply calcium alginate and cover with dry dressing daily and PRN. Wound #2 -- Left great toe plantar side clean with wound cleaner or normal saline, paint with betadine daily cover with dry dressing monitor for area opening. The unstageable wound measures 2.0cm x1.5cm area is not open at this time. During an interview on 09/17/25 at 3:00 p.m., the MDS nurse said she completed the MDS dated [DATE] for Resident #15. She reviewed the medical record for Resident #15 and said she just miscoded, and the pressure wounds should have been 2 unstageable pressure ulcers. Record review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual last updated May 2025 indicated .Code all high-risk drug class medications according to their pharmacological classification, not how they are being used. N0415I1. Antiplatelet: Check if an antiplatelet medication (e.g., aspirin/extended release, dipyridamole, clopidogrel) was taken during the 7-day observation period (or since admission/entry or reentry if less than 7 days). N0415I2. Antiplatelet: Check if there is an indication noted for all antiplatelet medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). Record review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual last updated May 2025 indicated . SECTION M: SKIN CONDITIONS Intent: The items in this section document the risk, presence, appearance, and change of pressure ulcers/injuries. Code all pressure ulcers since admission Stage 1, Stage 2, Stage 3, Stage 4 or unstageable.

Based on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 3 residents (Resident #15) reviewed for pressure injuries. The facility did not ensure WCN performed all the treatments for Resident #15 on 09/16/25 without surveyor intervention for 1 of 4 wounds. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain. Findings included: Record review of a face sheet dated 09/17/25 indicated Resident #15 was a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included Alzheimer's disease, osteoporosis (disease that weakens bones) with current pathological fracture and diabetes (too much sugar in the blood). Record review of a quarterly MDS assessment dated [DATE] indicated Resident #15 had a BIMS score of 99 and was unable to complete the BIMS. Resident #15 had memory problems with short term and long-term memories. The MDS indicated the number of unstageable pressure ulcers due to coverage of wound bed by slough (yellow or white tissue nonviable) and/or eschar (dark black tissue and dead tissue) was 1 and indicated no other pressure ulcers. Record review of the care plan dated 09/12/25 indicated Resident #15 had an actual wound measuring 1.4 cm x 1.1cm x 0.1cm. Medical device pressure stage 4 wound to the left lateral malleolus (ankle) 1.3 cm x 1.4 cm x 0.2 also and the left great toe plantar side (under side of the toe) 2.1 cm x 2. 1cm x UTD area is not open as of 09/11/25. Interventions included Treat as ordered by wound doctor, daily dressing change by nursing, and weekly skin checks. Record review of the physician's orders dated September 2025 indicated Resident #15 had treatments of Wound left lateral malleolus: clean with wound cleaner or NS apply medical honey to wound bed, cover with alginate, paint peri-wound with betadine and cover with dry dressing daily with start date 09/04/25. Wound plantar side left great toe -- clean area with wound cleaner or NS paint with betadine apply betadine-soaked gauze to wound bed and cover with dry dressing daily with start date 09/04/25. Left heel: paint with betadine and leave open to air daily with start date 09/02/25. Clean with wound cleaner or normal saline wound on the wound on the coccyx wound paint peri-wound with betadine apply collagen to bed, cover with dry dressing daily. Record review of the progress notes in the electronic medical record dated 08/28/25 indicated Resident #15 had 2 new unstageable wounds that were covered by the cast. The wound doctor identified these medical device pressure ulcers and are unstageable at this time. Wound #1- left lateral malleolus 4cm x 4cm x <0.1cm wound bed has 50% slough (yellow or white tissue consists of dead cells), 50% granulation (new tissue), with mild serous exudate (drainage), peri-wound (around the wound) intact. Notified wound doctor received new orders clean with wound cleaner or normal saline, paint peri-wound with betadine, cover wound bed with medical - honey, apply calcium alginate and cover with dry dressing daily and PRN.Wound #2 -- Left great toe plantar side clean with wound cleaner or normal saline, paint with betadine daily cover with dry dressing monitor for area opening. Wound measures 2.0cm x1.5cm area is not open at this time unstageable with eschar (dead skin). During an observation and interview on 09/16/25 at 10:15 a.m. the WCN was preparing to perform wound care to Resident #15. She donned gown and gloves and said Resident #15 was in EBP. She went into the room and prepared the resident for wound care providing privacy and she spoke Spanish to Resident #15. #1 The WCN performed wound care for the area on coccyx (end of the spine). She cleaned the coccyx wound with wound cleanser and painted around the wound with betadine and applied collagen to the wound bed, covered with dry dressing. She performed as needed glove change and hand sanitization for Resident #15 wound on her coccyx. #2 Resident #15 relaxed while the WCN removed her gloves and cleaned her hands with sanitizer and applied new gloves and removed the dressing to the ankle wound and removed gloves, hand sanitizer then donned new gloves. She cleaned the wound from inside out with the wound cleanser. She removed her gloves and donned new gloves without hand sanitizer, applied medical honey to wound bed, covered with alginate, painted peri-wound with betadine and covered with dry dressing. #3 The WCN changed gloves with no hand hygiene was performed before she applied the new gloves. Then she removed the dressing on the left great toe removed her gloves and with no hand hygiene donned new gloves, cleaned the wound with wound cleanser and applied betadine-soaked gauze and covered with dry dressing. Then the WCN removed her gloves and washed her hands and said she had finished wound care for Resident #15. The surveyor intervened and asked if Resident had any more areas and the WCN said no. Then when surveyor asked about the area to the upper part of the heel the WCN said yes, Resident #15 does have an open area there and said it just opened a few days ago and had treatment for that area. She said she had just gotten nervous and forgot.#4 So then she donned new gloves and painted the back of the left heel with betadine and left open. She removed her gloves and washed her hands. Record Review of the Wound Care policy dated October 2010 indicated . The purpose of this procedure is to provide guidelines for the care of wounds to promote healing. Verify the physician's orders .

Based on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #12) for pharmacy services.* The facility did not clarify Resident #12's physician order for Flonase when the order was unclear. MA D administered Resident #12's Flonase nasal spray (used to treat allergies) 1 spray to each nostril during medication pass. The physician order indicated 1 spray nasal. This failure could place residents at risk of not receiving the therapeutic dosage of their medications.Findings included: During an observation on 09/17/2025 09:25 a.m. during medication pass, MA D administered Flonase nasal spray 1 spray to each nostril to Resident #12. Record review of physician orders for September 2025 indicated Resident #12 had an order dated 01/31/25 for Flonase Allergy Relief (fluticasone propionate) spray, suspension; 50 mcg/actuation; amt: 1 spray; nasal once a day; 09:00 a.m. There was no indication as to which nostril to administer the spray. Record review of September 2025 MAR indicated Resident #12 received Flonase Allergy Relief (fluticasone propionate) spray, suspension; 50 mcg/actuation; amount to administer: 1 spray; nasal once a day. There was no indication as to which nostril to administer the spray. During a record review and interview on 09/17/25 at 04:00 p.m. MA D reviewed Resident #12's order for Flonase and said the order did not indicate if the spray was to be administered in 1 nostril and which nostril or that it was to be administered into each nostril. MA D pulled the Flonase box to review the prescription label and it indicated 1 spray to each nostril daily. During a record review and interview on 09/17/25 at 04:10 p.m. the DON, LVN C, and the Administrator acknowledged the unclarity of Resident #12's Flonase order. LVN C said she would get a clarification on the order. LVN C and the DON said the medication would not be administered correctly the way the order read. The DON and Administrator said they expected medications to be administered correctly, or residents would not get the medications the way they were supposed to get them. Record review of an Administering Medications policy revised April 2019 indicated .Policy Interpretation and Implementation:.10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

Based on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service. The facility did not ensure the gas stove was in working order on 09/15/25. One of six gas stove burners (left back) did not light automatically, when the knob was turned to the on position on 09/15/25. This failure could place residents who eat out of the kitchen at risk for injury and under-cooked food and risk of food borne illnesses. Findings include: During an observation and interview on 09/15/25 at 7:55 a.m., revealed the gas stove had six burners total and One burner located in the left back, would not light automatically. The DM said they had to light it with matches sometimes. During an interview on 09/17/25 at 7:55 a.m., the Administrator said she expected staff to notify her of issues with equipment. She said she just trained all the dietary staff on the dish machine last week. She said food borne illness was a potential hazard for the dishwasher not working properly. She said the burner was fixed immediately. Record review of facility policy titled Sanitization dated revised November 2022 indicated . Dishwashing machines are operated according to manufacturer's instructions. b. Low - Temperature Dishwasher (Chemical Sanitization). (1) Wash temperature (120 Fahrenheit); (2) Final rinse with 50 parts per million (ppm) on dish surface in the final rinse; and (3) The chemical solution is maintained.

Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 (A Hall) of 3 hallways reviewed for environment. An empty unlocked resident room was being used as a storage room on A Hall and contained potentially unsafe items. This failure could result in residents coming into contact with potentially unsafe items. The findings were: During an observation on 09/15/2025 at 9:35 a.m., during the initial tour on hall A revealed an empty room with the door shut and unlocked. There was a container of pesticide powder that was half full on a dresser in the unlocked room. The container had a label which indicated to keep out of reach of children and animals. Personal safety Warnings indicated to avoid contact: Do not get dust on skin, in eyes, or on clothing. There was no staff in sight. During an interview on 09/15/25 at 9:45 am. the Maintenance Supervisor walked down the hall and met the surveyor at the unlocked room. He said he forgot to lock the door, and he knew better because they had residents who were confused and wandered about the facility. He said all chemicals should be in sight or locked up. During an interview with the Administrator on 09/16/25 at 1:30 p.m., the Administrator said the maintenance supervisor locked the door after he had forgotten. She said he replaced the lock with a self-locking door after surveyor intervention.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure steam table lids did not have brown colored buildup on the inside edges.* The facility did not ensure baking sheets did not have brown colored buildup on the outside edges.* The facility did not ensure muffin pan did not have brown colored buildup on the inside and outside edges.* The facility did not ensure saucepans did not have brown colored buildup on the inside and outside of the pans. These failures could place all residents who eat from the kitchen at risk for foodborne illnesses. Findings included: During an observation on 08/26/2025 at 03:55 p.m. during a of the kitchen indicated there were the following:-one (1) 1/2 size baking sheet with dark brown colored build up on the outside edge;-two (2) full size baking sheets with dark brown colored buildup on the outside edges and stacked together;-one (1) large muffin pan dark brown colored buildup on the outside edges and stacked a medium muffin pan on it;-two (2) steam table lids had brown colored buildup on the inside edges;-two (2) large saucepans with brown colored buildup on the inside and outside; and-one (1) medium saucepan with brown colored buildup on the inside and outside. During an interview on 08/26/25 at 03:59 p.m. DA A said they had been scrubbing the pots and pans trying to get the brown build up off of them. During an interview on 08/26/25 at 04:15 p.m. the DM said the pots and pans were a work in process trying to get the buildup off of them. He said the outcome could be food borne illnesses from the dishes not being sanitized properly. During an interview on 08/26/25 at 05:28 p.m. the Administrator said the DM was told to rotate and replace pots and pans when needed. Record review of a Sanitization Policy revised November 2022 indicated: Policy: The food service area is maintained in a clean and sanitary manner.Policy Interpretation and Implementation:. 3. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. According to The Food and Drug Administration Code at http://www.fda.gov/food/guidanceregulation accessed on 08/26/25 indicated the following: .4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils.(B)The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations

Based on interview and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections was established and maintained to prevent the spread of infections for all residents in the facility. The facility did not maintain a system of trending infections within the facility for the months of July 2023 through July 2024. This failure could place residents at risk of cross contamination and the development of infections. Findings included: Record review of a facility census sheet dated 08/05/24 indicated facility census was 31. Record review of the facility's infection control tracking and trending binder did not include any documentation of infection trending for the months of July 2023 through July 2024. During an interview on 08/06/24 at 3:20 p.m., the Administrator said that the Regional MDS Nurse was the Infection Control Nurse for the facility. During an interview on 08/07/24 at 12:39 p.m., the Regional MDS Nurse said the previous DON had left the facility in July 2024 and had deleted facility computer records before she left. He said he believed the trending of infections records had been deleted. He said he took over the position of DON and Infection Control Nurse after the DON left, but he did not complete any trending of infections. He said trending was done to document the type of infection, possible common bacteria, and the area of the facility in which the infection occurred. He said the possible negative outcome of not trending infections was increased and continuous infections and the spread of infection among the residents. During an interview on 08/07/24 at 12:46 p.m. the Administrator said she thought to previous DON had deleted the files that recorded the trending of infections in the facility. She said the previous DON left on 07/19/24. She said she expected all infections in the facility to be tracked and trended to make the facility staff aware of what infections were occurring and develop an ongoing and effective infection prevention program. She said the possible negative outcome of not trending infections could be the rise of infections in the facility. Record review of a facility policy titled Surveillance for infections revised September 2017 indicated .The purpose of the surveillance of infections is to identify both individual cases and trends of epidemiologically significant organisms and healthcare-associated infections, to guide appropriate interventions, and to prevent future infections .

Based on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 12 residents reviewed for accuracy of assessments. (Resident #'s 4 and 12) The facility did not accurately complete the MDS assessment to indicate Resident #4 was not receiving an anticoagulant and no longer received an antidepressant medication. The facility did not accurately complete the MDS assessment to indicate Resident #12 smoked. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings included: 1. Record review of a face sheet dated August 2024 indicated Resident #4 was a [AGE] year-old-female readmitted [DATE] with diagnoses of dementia (a group of thinking disorders that interfere with daily functioning), anxiety (intense, excessive and persistent worry and fear about everyday situations) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Record review of the quarterly MDS assessment dated [DATE] indicated Resident #4 had a BIMS score of 3 indicating severely impaired cognition. The assessment indicated the resident received an anti-coagulant (e.g. warfarin, heparin, or low-molecular weight heparin (a class of anticoagulants used for treatment of blood clots) and received an antidepressant medication (medication to treat depression). Record review of physician orders dated August 2024 indicated Resident #4 did not receive an anticoagulant or antidepressant medication. Record review of a care plan updated 07/07/24 indicated Resident #4 had a history of depression. Record review of the MAR dated 07/06/21 through 07/03/24 indicated Resident #4 received an antidepressant medication duloxetine 30 mg every other day from 03/01/24 with an end date of 03/25/24 and received no anticoagulant medication, only aspirin (a blood thinning medication) 81 mg daily, that cannot be coded as an anticoagulant medication on the MDS. During an interview on 08/05/24 at 09:45 a.m., Resident #4 said she was treated well and denied pain. She was oriented to self but was confused and unsure of what medication she was prescribed. 2. Record review of a face sheet dated August 2024 indicated Resident #12 was a [AGE] year-old-male readmitted [DATE] with diagnosis of chronic obstructive pulmonary disease (COPD- a group of lung diseases that block airflow and make it difficult to breathe). The face sheet indicated Resident #12 was a current everyday smoker. Record review of a significant change in status MDS assessment dated [DATE] indicated Resident #12 had a BIMS score of 15 indicating intact cognition. The assessment indicated Resident #12 had a diagnosis of COPD and did not indicate current tobacco use. Record review of a Smoking Risk assessment with an observation date of 10/09/23 indicated Resident #12 smoked cigarettes every few hours and was a safe smoker. Record review of a care plan updated 05/15/24 indicated Resident #12 was a smoker and required supervision while smoking. During an observation and interview on 08/05/24 at 11:09 a.m., Resident #12 was observed smoking safely during the smoking time. Staff were observed providing his smoking supplies and monitoring during the smoking time. Resident #12 said he smoked every day and the staff kept his supplies and monitored him while smoking. During an interview and record review on 08/06/24 at 3:25 p.m., the Regional MDS nurse said he was responsible for all the MDS assessments in this facility as of July 2024. He said he completed Resident #4's quarterly MDS that captured an anticoagulant and antidepressant medication and after medical record review, they should not have been captured due to the resident no longer receiving the medication. The Regional MDS nurse said aspirin should not have been captured on the MDS. He said it was captured by the system from a previous MDS and should have been removed. The Regional MDS nurse said Resident #12's Significant change MDS that was completed by a previous MDS nurse, did not capture Resident #12 's smoking and should have captured it. He said it was overlooked. He said Resident #12 smoked daily since admission. The Regional MDS nurse said the Regional Consultant was his backup for double checking for MDS completeness and accuracy. The Regional MDS nurse said he was educated on MDS completion and accuracy. He said the risk of items not being captured correctly on the MDS was state inspectors and staff could be misinformed of the resident's status and not get a correct picture of the resident which could lead to a nurse not following the plan of care. During an interview on 08/06/24 at 3:50 p.m., the DON said the Regional MDS nurse was responsible for all MDSs in the facility and the Regional Consultant was his back up to check MDSs for accuracy. The DON said he was unsure why Resident #4's MDS was not captured correctly. The DON said his expectation was for all MDSs to be completed accurately and completely. During an interview on 08/07/24 at 8:17 a.m., the Administrator said the Regional MDS nurse was responsible for all MDSs in the facility and the Corporate MDS nurse was his back up and double checked MDSs for accuracy. She said Resident #4's MDS captured an anticoagulant and antidepressant medication that Resident #4 was not receiving and they should not have been captured. The Administrator said Resident #12 smoked daily and smoking should have been captured on his MDS. She said all items on the MDS should be correct. The Administrator said the Regional MDS nurse was educated on MDS completeness and accuracy. She said her expectation was to capture everything accurately on the MDS. The Administrator said the risk of incorrectly captured items on a MDS was the resident may not receive needed care. During an interview on 08/07/24 at 11:37 a.m., the Regional Consultant said the Regional MDS Nurse was responsible for the MDSs in the facility. He said he was not the back up and did not audit MDSs for accuracy. The Regional Consultant said he monitored MDSs for timeliness and provided training and new guidance. He said the Regional MDS nurse was educated on MDS completeness and accuracy. The Regional Consultant said the risk to a resident of items captured inaccurately was the MDS was a data collection tool that drives the care plan that drives resident care and observations. Record review of the facility policy revised November 2019, titled, Electronic Transmission of the MDS indicated, . All MDS assessments . are completed and electronically encoded into our facility's MDS information system and transmitted to CMS' QIES Assessment Submission and Processing system in accordance with current OBRA regulations governing the transmission of MDS data Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . N0415: High-Risk Drug Classes: Use and Indication 1. Is taking: Check if the resident is taking any medication by pharmacological classification, not how it is used during the last 7 days or since admission/ reentry or reentry if less than 7 days. N0415C1. Antidepressant: check if there is an indication noted for all antidepressant medications taken by the resident any time during the observation period N0415E1. Anticoagulant (eg., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at anytime during the 7- day look back period.Coding Tips and Special Populations . Do not code antiplatelet medication such as aspirin/ extended release, dipyridamole, or clopidogrel as N0415 E, Anticoagulant. Record review of, Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual dated October 2023 indicated, . J1300: Current Tobacco Use. 0. No 1.0 Yes 1. Ask the resident if they used tobacco in any form during the look back period. 2. If the resident states that they used tobacco in some form during the 7-day look back period code 1. Yes .

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 18 residents reviewed for care plans. (Resident #s 2 and 3) The facility did not develop a care plan for Resident #2's trauma induced wound to her right heel. The facility did not develop a care plan for Resident #3's Hospice services. These failures could place the residents at risk of not receiving the care and services to maintain their highest level of well-being. Findings included: 1.Record review of a face sheet dated 08/06/24 indicated Resident #2, readmitted [DATE] was an [AGE] year-old female with diagnosis of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (occurs when blood flow to the brain is blocked) affecting right dominant side. Record review of a quarterly MDS assessment, dated 06/17/24 indicated Resident #2 was cognitively intact, was independent with bed mobility and required partial/moderate assistance with transfers. Record review of physician orders for Resident #2 dated 07/26/24 indicated: clean wound to right posterior heel with wound cleaner, apply betadine around the wound, wound dres to the wound bed, cover with collagen and a dry dressing daily. Record review of the care plans indicated Resident #2 did not have a care plan for the wound on her right posterior heel. During an interview on 08/07/24 at 10:50 a.m., Resident #2 said the Treatment Nurse was taking care of her wound every day. During an interview on 08/07/24 at 10:55 a.m., the Treatment Nurse said she was responsible for writing care plans for new wounds, and she had never written a care plan for Resident #2 right posterior heel wound. She said the wound was discovered on 07/26/24 and during that time the Corporate MDS Nurse was her direct supervisor. She said not writing a care plan for a new wound could result in inconsistencies in care and deterioration of the wound. During an interview on 08/07/24 at 11:14 a.m., the Regional MDS Nurse said he had been the Treatment Nurse's direct supervisor when Resident #2's wound was discovered on 07/26/24 and a care plan was not written. He said the treatment nurse was responsible for writing care plans for new wounds, but he was ultimately responsible because it was his responsibility to ensure care plans were complete and accurate for all residents. He said his expectation was for residents to have a person-centered care plan which addressed all of the resident's current care and treatments. He said not having a care plan to address a new wound could result in the resident not receiving care as ordered by the physician. 2. Record review of a face sheet dated 08/07/24 indicated Resident #3, readmitted [DATE] was a [AGE] year-old male with a diagnosis of cerebral infarction due to embolism (a stroke that occurs when a blood clot or plaque debris blocks the blood flow to the brain). Record review of physician orders dated 8/7/24 indicated Resident #3 was admitted to hospice services on 10/30/23. Record review of the quarterly MDS assessment dated [DATE] indicated Resident#3 was on hospice services. Record review of the care plans indicated Resident #3 did not have a care plan for Hospice services. During an interview and record review on 08/06/24 at 3:55 p.m., the Corporate MDS nurse said he was responsible for ensuring the comprehensive care plans were accurate for each resident. During record review of Resident #3's clinical record, he said Resident #3 did not have a hospice care plan and should have because he was receiving hospice services. He said the possible negative outcome of not having a hospice care plan would be the resident may not receive coordination of services and not receive the appropriate care they needed. During an interview on 08/07/24 at 12:05 p.m., the Administrator said every resident should have a person centered care plan. She said the DON was ultimately responsible that care plans addressed all care and treatments of the residents. She said the Regional MDS Nurse was the interim DON during the time these care plans were not written. Record review of a Care Plans, Comprehensive Person-Centered policy revised March 2022 indicated: Policy Statement-A comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. 36214

Based on observations, interviews, and record reviews, the facility failed to provide basic life support, including CPR to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 31 residents reviewed for CPR. Resident #1 was found unresponsive on [DATE] around 4:00 a.m. by CNA B who immediately notified LVN A. LVN A failed to verify Resident #1's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 2.5 hours after the resident was found to be unresponsive. The facility did not immediately provide CPR and call 911 for Resident #1 who was a full code (wanted all possible life saving measures in the event his heart or breathing stopped) when the resident was found unresponsive by CNA B. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life saving measures including CPR and could lead to death. Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included cerebrovascular disease, pneumonia, and anoxic brain damage. (Brain was deprived of oxygen causing brain cells to die) Record review of Resident #1's significant change MDS dated [DATE] indicated he had a BIMS score of 11 out of 15, which indicated his cognition was moderately impaired. Record review of Resident #1's care plan dated [DATE], indicated Resident #1 had code status as Full Code. Interventions included advanced directives will be kept in chart. If resident was found with no pulse and/or respirations, notify physician, EMT's, and begin CPR. Record review of Resident #1's progress notes dated [DATE] at 4:15 a.m., documented by LVN A stated Resident was found with no signs of life, Hospice notified, and stated they would be here as soon as she can. Stated she will call family and funeral home. Message left for ADON. During an interview on [DATE] at 12:15 p.m., CNA B said she had been employed at facility since February 2024. She said she received orientation including Abuse/Neglect. She said she took the CPR class offered at the facility on [DATE]. She said staff knew of the resident's code statuses in the computer next to their name. CNA B said there was also a binder on the crash cart with every resident's code status and paperwork. She said she made rounds on residents about every ,d+[DATE] hours. She said on [DATE] while working her shift, she saw Resident #1 around 2:30 a.m., and he was fine. She said on her next rounding at 4:00 a.m., he was unresponsive. She said his lips were white and his nailbeds were blue/purple, and his body was warm to the touch. She said she yelled for the nurse. She said the nurse went and looked at him and went back to the nurse's station. CNA B said she told the nurse she thought the resident was a full code. She said LVN A threw her hands up in the air and told her the resident was a hospice patient and there was not anything she could do for him. CNA B said she told the nurse she should do something, and the nurse told her he was already gone, and it was too late. CNA B said the nurse did not start CPR or use the AED while she was in facility. CNA B said postmortem care was performed. CNA B said when her shift was over at 6:00 a.m., the resident was still in facility and the LVN A had done nothing. During a phone interview on [DATE] at 2:09 p.m., LVN A said on [DATE] at approximately 4:00 a.m., CNA B summoned her to Resident #1's room. LVN A said when she entered his room, Resident #1's face looked like candle wax. She said he had no pulse, heartbeat, or respirations. LVN A said they turned him, and he had rigor mortis (rigor mortis-stiffening of the joints and muscles of a body a few hours after death). Next, she called the hospice agency at 4:15 a.m. and informed the service of his death. She said the hospice on-call nurse returned her call and told her it would take about 1.5 hours for her to arrive. LVN A said after she hung up with the hospice nurse, she then went about her duties and prepared medications that were due before the end of her shift for other residents. She said when the hospice nurse arrived at 6:30 a.m., the hospice nurse told her the resident was a full code. LVN A said the hospice nurse said she could not pronounce the resident as deceased because he was a full code and CPR or EMS had not been activated. LVN A said she clocked out of her shift and was on her way home when LVN D phoned her to return to the facility. LVN A said after returning to facility, she initiated CPR and hooked up the AED to Resident #1. This was approximately 2.5 hours after finding Resident #1 unresponsive. She said EMS arrived and pronounced Resident #1 dead. She stated, I did not know he was a full code and how can they be with hospice? She added It is fully my fault. I did not check his code status. I knew where to look but it never crossed my mind. She stated I was worried about getting my work done. People are getting fired left and right around here. She said she had been a nurse since 1985 and had done CPR in the past but never on a hospice patient. Record Review of a hospice note for Resident #1's incident indicated the hospice RN arrived at the facility on [DATE] at 6:36 a.m. She noted receiving a call from the hospice answering service that LVN A had reported Resident #1 expired. The hospice RN returned the call to the facility and gave her an estimated time of arrival. Upon arrival to facility, learned that EMS had not been called and no CPR initiated. Pt. was a full code. Informed LVN that EMS needed to be called and CPR initiated. Ambulance service responded and took over from LVN who was doing CPR at bedside. They pronounced patient at 7:32 a.m. During a phone interview on [DATE] at 1:00 p.m., the Hospice RN said she received a message through the hospice answering service that Resident #1 had expired. She said when she arrived at the facility around 6:30 a.m., she opened her computer and saw that the resident was a full code. She asked the facility staff about CPR or calling 911. She said LVN A told her there was a note on his chart saying not to send out to the hospital and this was the reason she did not initiate CPR. She said apparently the nurse exited the facility after her shift and the hospice RN told them to get her back to finish up with the resident. She said LVN A returned and initiated CPR and another staff called EMS. She said she could not pronounce because the resident had been a full code and CPR had not been initiated until after she arrived and was made aware. During an interview on [DATE] at 9:30 a.m., the Administrator said she was notified by MA C of the situation with Resident #1 at approximately 6:30 a.m. She said LVN A said she believed she did nothing wrong because the resident was a hospice patient. The Administrator said LVN A told her the resident was cold to the touch when she found him. She said the nurse called hospice and was told by the hospice nurse that she must do something because the resident was a full code. She was told to call EMS by the hospice nurse. The Administrator said the on-call hospice nurse came to the facility and would not pronounce this resident because the facility nurse had not initiated CPR. She said finally LVN A called EMS and began CPR when she returned to facility approximately within 10 minutes of leaving the facility. The spouse was also called and came to facility. The Administrator said LVN A had not been employed at the facility for a long amount of time and had been a nurse for over [AGE] years. She said LVN A was CPR certified. The Administrator said LVN A was suspended pending investigation, and on the next day, had phoned to see when she could come back to work. She said LVN A seemed to believe she had done nothing wrong and wanted to return to work. She said all nurses currently were CPR certified and a CPR class was held on Friday after the incident (occurred on Wednesday). She said she held mock codes on Friday and one on Saturday for the staff due to the incident. Her expectations were for all staff to be knowledgeable of the code process and to feel comfortable performing CPR on residents should the occasion arise. Any direct care staff not current on CPR were not allowed to work on floor until current. Following a facility investigation, LVN A was terminated from facility on [DATE]. During an interview at on [DATE] at 12:50 p.m., MA C said she started working at the facility in [DATE]. She said she had attended CPR class offered by the facility following this incident. She said there was a binder on top of the crash cart at the nurses' station which contained all information of the residents' code statuses. She added staff could also look in the computer. She said when she arrived at the facility for her shift, LVN A told her Resident #1 had passed away. She said LVN A told her she had left a message for the DON but had not informed the administrator of resident's death. She said she called the administrator to inform her, and that the administrator was unaware of death at that time. During an interview on [DATE] at 1:40 p.m., the DON said she received a text from the Administrator at 7:00 a.m. informing her of Resident #1 passing away and CPR had not been initiated. She said she arrived at the facility at 8:15 a.m. She said when the nurse for the day shift arrived for her shift at 6:00 a.m., the hospice nurse was freaking out because no one had initiated CPR on Resident #1 and that someone should call EMS/911. The DON said LVN A told her the resident was a hospice patient and the DON told her she still had to do CPR. The DON said LVN A had not informed the resident's physician, the DON, or Administrator of the incident prior to their arrival. The DON said the resident's medical record indicated what specific hospital Resident #1's spouse did not want the resident sent to, but there were other hospital facilities available. She said LVN A knew the resident was a full code. She added how could you be a nurse for [AGE] years, or 4 days, and not know you have to do CPR? To ensure all staff received the trainings, she said a CPR audit was conducted on all direct care staff. Any direct care staff not current on CPR were not allowed to work on floor until current. Mock codes utilized a CPR dummy and there was return demonstration. DON/designee will perform monthly audit of direct care staff to ensure all were current on CPR. Current CPR certification will be verified on all new hires of direct care staff. Will perform random mock codes. During a phone interview on [DATE] at 2:00 p.m., LVN D said she worked the day shift. She said during report on [DATE] at 6:00 a.m., she was informed Resident #1 had expired. She said the hospice RN arrived around 6:30 a.m. and started asking questions about the resident such as, had CPR been initiated and had first responders been notified. LVN D said she told the hospice nurse that all she had been told was that the resident had passed. She said the hospice nurse wanted LVN A to come back to facility, so she called her to return. She said after LVN A and the hospice RN spoke, LVN A called EMS and went to the room to initiate CPR. LVN D said she had been a nurse for [AGE] years and had been at the facility for about one month. She was able to explain code status and response with the state surveyor. During interview on [DATE] at 11:00 a.m., the ADON said LVN A called her about 4:30 a.m. on [DATE] but she did not hear her phone. She said later that morning, when she listened to the voicemail, the message was to inform her of Resident #1 passing. She was not aware of the situation until she arrived at the facility around 7:30 a.m . Reviewed crash cart and AED documents on [DATE] at 11:15 a.m. The crash cart had a binder with a list of every resident's code status with copies of advance directives and out-of-hospital DNRs. Residents with full codes had green sheets with their name and room number in big, bold letters. On [DATE] at 4:00 p.m., the Administrator was informed of the Immediate Jeopardy. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. The facility implemented the following interventions: -Immediate suspension of LVN A -CPR audit conducted on all direct care staff -Abuse/Neglect in-service -in-service on emergency procedures for codes (CPR) -Performed 3 mock codes with more planned -held CPR training recertification class These interventions were verified by state surveyor. Review of Provider Investigation Report dated [DATE] indicated the following: *Provider Response - Nurse was immediately suspended pending investigation. Family, physician, NP and local law enforcement notified. Facility wide re-educationinitiated. *Investigation Summary - Nurse did not initiate CPR or call 911 to a full code hospice resident when she found him with no signs of life at 4:15 a.m. *Investigation Findings - confirmed *Provider Action Taken Post - Investigation - Nurse suspended pending investigation. In-service on code status, neglect and proper reporting procedures initiated. Facility verified that all direct care staff has current CPR certification. Mock codes initiated for all shifts. CPR class provided. Record review of training held on [DATE] indicated facility held an in-service on General Abuse and Neglect for all Nursing staff. There were 35 staff members who attended. Record review of training held on [DATE] indicated facility held an in-service on Emergency Procedure for Codes and Documentation. There were 21 in attendance. Record review of training held on [DATE] indicated facility held training on CPR and First Aid and AED. There were 10 direct care staff who updated their CPR cards by recertification. Record review of training for Mock Code - with education on code status emergency response provided held on [DATE] with 4 nursing staff participating. Record review of training for Mock Code - with education on code status emergency response provided held on [DATE] with 4 nursing staff, a housekeeper and a therapy person participating. Record review of training for Mock Code - with education on code status emergency response provided held on [DATE] with 6 nursing staff participating. During interviews on [DATE] from 11:00 a.m. through 4:30 p.m., 3 CNAs (CNA B, CNA G, and CNA H) were able to identify abuse/neglect, were knowledgeable of resident code status, and knew where to locate information of new resident's code status. They were aware of expectations to begin CPR immediately if resident was found unresponsive and was a full code. Each had engaged in the mock code drills performed following this incident. During interviews on [DATE] from 11:00 a.m. through 4:30 p.m., 1 LVN (LVN D) and 3 MAs (MA C, MA E, and MA F) were able to identify abuse/neglect, were knowledgeable of resident code status, and knew where to locate information of new resident's code status. They were aware of expectations to begin CPR immediately if resident was found unresponsive and was a full code. Each had engaged in the mock code drills performed following this incident. During interviews on [DATE] from 11:00 a.m. through 4:30 p.m., the DON, the ADON, the RN supervisor, and Maintenance supervisor were able to identify abuse/neglect, were knowledgeable of resident code status, and knew where to locate information of new resident's code status. They were aware of expectations to begin CPR immediately if resident was found unresponsive and was a full code. Each had engaged in the mock code drills performed following this incident. Record review of an Emergency Procedure - Cardiopulmonary Resuscitation policy dated February 2018 indicated: . Personnel have completed training on the initiation of Cardiopulmonary Resuscitation (CPR) and basic life support, including defibrillation, for victims of sudden cardiac arrest. General Guidelines 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR shall initiate CPR unless: a) it is known that a Do Not Resuscitate order that specifically prohibits CPR and/or external defibrillation exists for that individual or b) there are obvious signs of irreversible death. 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began.

Based on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure injury and does not develop pressure injury unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 2 (Resident #1 and Resident #2) of 10 residents reviewed for pressure injuries in that: 1.The facility failed to provide assessments, treatment for pressure injuries and notify physican to Resident #1's right dorsal foot pressure injury when it deteriorated to an unstageable wound with eschar from 02/14/2024 to 2/27/2024 where it declined to requiring wound irrigation, debridement, and graft application during her hospitalization on [DATE]. 2. The facility failed to provide assessments, treatment for pressure injuries and notify physican to Resident #2's blister to right heel when it deteriorated to an unstageable wound with eschar from 3/16/24 to 3/22/24. An Immediate Jeopardy (IJ) was identified on 03/21/2024. The IJ template was provided to the facility on [DATE] at 5:09 p.m. While the IJ was removed on 03/23/2024 at 1:00 p.m., the facility remained out of compliance at a scope of a pattern and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place. This facility failure could place residents at risk of untreated wounds, infection, a decline in health, further surgeries with associated complications leading to death. Findings included: Record review of Resident #1's electronic face sheet dated 03/13/2024 indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: displaced trimalleolar fracture of right lower leg (fracture of lower leg bone, connected to foot/ankle area), Other acute osteomyelitis (infection of the bone), left ankle and foot, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue-Right ankle ORIF (surgical procedure to replace bones with hardware or attach hardware to fix broken bone), Need for assistance with personal care, Muscle weakness (generalized), End stage renal disease ( a medical condition in which a person's kidneys cease functioning on a permanent basis leading to need for a regular course of long-term dialysis or a kidney transplant to maintain life), Cognitive communication deficit, metabolic encephalopathy ( another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), hypertension condition in which the force of the blood against the artery walls is too high, Diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's MDS dated [DATE] indicated she had no pressure injuries. She scored a 15/15 on her BIMS which signified she was cognitively intact. She was incontinent of bowel and bladder and went to dialysis 3 x week for hemodialysis for her end stage renal disease. She required substantial/maximal assistance with her ADLs. Record review of Resident #1's comprehensive care plan date initiated 12/15/2023 and revised on 03/01/2024 indicated Problem .has surgical wound to right ankle with pins in place .Approach . Assess condition of surrounding skin. Report emergence of skin excoriation. Observe and report signs of localized infection, (localized pain, redness, swelling, tenderness, loss of function, heat at the infected area.) Further review indicated Problem . potential for impaired skin integrity R/T impaired mobility. Approach . Assess feet every shower day & as needed, noting color, peripheral pulses, sensory reflexes, temperature, presence of edema or verbalizations of pain. Assess skin weekly & as needed & document changes. Record review of Resident #1's Braden Skin assessment dated [DATE] indicated she scored a 19 which signified she was at a low risk for skin breakdown. No current Braden Skin Assessment noted in medical records. Record review of Resident #1's Orders As of: 12/14/2023 to 02/27/2024 indicated: Treatments .to provide weekly skin assessment once a day on Monday 6:00 a.m. - 6:00 p.m. Dated 11/09/2023. Further review indicated Treatments . check skin surrounding splint to right leg. Check for capillaries refill to lower extremity Q shift and PRN. Notify MD of any abnormalities or changes in skin condition. Every Shift: day shift 06:00 a.m. - 06:00 p.m., night shift 06:00 p.m. - 06:00 a.m. Dated 11/23/2023 Ended 02/26/2024. Wound Treatments: cleanse pin site to right ankle surgical site with peroxide once a day every other day 06:00 a.m. - 06:00 p.m. Dated 12/15/2023. Ended 02/27/2024. Record review of Resident #1's Skin - Dignity Weekly Skin assessment dated [DATE] authored by RN C indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Orthopedic progress note dated 02/14/2024 authored by orthopedic MD indicated that Resident #1 was being seen status post right ankle fusion with hardware removal with external fixator and pins placement on 12/11/2023. The external fixator frame was in place to RLE, swelling was mild, incision healed. Mild redness on the proximal medial and lateral pins. Abrasion with some black scabbing proximally 2cm x 2cm on the top of right foot. Record review of Resident #1's Skin - Dignity Weekly Skin assessment dated [DATE] authored by LVN A indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment due 02/26/2024 not found in medical records. Record review of Resident #1's progress notes from 02/14/2024 to 02/27/2024 revealed no documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or pressure injury to right buttocks. Record review of resident #1's TAR dated February 2024 did not have an assessment or treatment for pressure injury/wound on top of right foot or pressure injury to right buttocks. Record review of Resident #1's Progress Note dated 02/23/2024 authored by LVN A, indicated that CN was made aware by CNA that resident's right foot dressing had blood leaking. CN noted resident's right foot with dried blood on skin and pins, with white spots with clear drainage on side of foot too. CN cleaned wound per wound care order, DON, ADON, Administration, and MD notified of findings, no new orders given. Record review of Resident #1's Progress Note dated 02/25/2024 authored by LVN A, indicated that CN nurse cleaned residents' Right foot per wound care order, right foot had purulent drainage, with dried blood, RP notified, MD was already made aware upon first finding on 02/23/24. DON notified, ADON notified. Will monitor. V/S WNL limits. Resident denies any pain or discomfort at this time. Record review of Resident #1's Progress Note dated 02/26/2024 authored by DON G indicates that the facility NP was notified regarding skin integrity and pictures were sent to NP. New orders for stat labs to be obtained and schedule an ortho visit ASAP. Record review of Resident #1's image of RLE dated 02/25/2024 and 02/26/2024 indicated that resident has a dark area to top of right foot with redness noted around wound. Record review of Resident #1's Progress Note dated 02/27/2024 authored by NP indicated that Resident #1 was seen today after having hemodialysis (a machine filters waste, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) session this morning. She continued to have drainage from RLE hardware x 5 days, the entry points in the heel, middle, and upper portions of the hardware have purulent drainage. She is c/o significant pain. She has an appointment with Ortho scheduled for tomorrow, but labs from 02/26/2024 show leukocytosis of 17.9 which is concerning. Spoke with orthopedic MD on the phone and he advised transferring Resident #1 to affiliated hospital for evaluation. Record review of Resident #1's hospital record dated 02/27/2024, indicated Diagnosis: Chronic osteomyelitis (infection in the bone) of the right ankle, has external fixator, infection at sites of external fixator pins and right dorsal foot wound (pressure injury). Resident #1 underwent manipulation of external fixature, pin exchange and irrigation and debridement with application of integra graft to right dorsal foot (pressure injury site) on 02/29/2024. Skin head to toe assessment completed in hospital ER dated 02/27/2024 indicated Resident #1 was found to have pressure injury to right lateral buttock, measuring 2 cm x 2cm - images indicate site missing top layer of skin, pink in color, and a pressure injury to right dorsal foot measuring 2 cm x 4 cm - images indicate black/eschar tissue with redness around wound site. Plan: The patient has had some issues with the pin sites, we recommend surgery to evaluate exchange of pins. The resident was admitted for IV antibiotics, pain management and surgical intervention. Recommend compression of the ankle fusion through the frame and debridement of the dorsal midfoot wound. Resident #1 underwent surgical intervention of right ankle manipulation of external fixator pin exchanged and wound irrigation, debridement, and graft application to right dorsal foot pressure injury/wound on 02/29/2024. Resident #1 was discharged on [DATE] to another nursing facility with orders to continue IV antibiotics for 8 weeks and to provide care to pressure injury/wound to right dorsal foot and pin sites daily and to follow up with infectious disease and orthopedic physicians. Interview on 03/13/2024 at 2:30 p.m. with LVN A, indicated that she cared for Resident #1, she was a CN on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care, cleansed each site with hydrogen peroxide, and wrapped RLE/external fixator with ace wrap during her shift. LVN said that resident had an external fixator/halo device to RLE status post hardware removal following ankle fracture and CN was responsible to provide pin site care every other day. LVN said her pin sites started looking red, macerated, and purulent drainage on 02/23/2024 and reported the findings to DON, ADON, Administration, and MD notified of findings, no new orders given. LVN A does not recall assessing or providing treatment to an area on top of Resident #1's right foot. LVN A indicates that she took a photo of the resident's right lower extremity/foot and sent it to the DON due to her concerns with the external fixator pin sites. LVN A said the care provided and concerns was focused on the external fixators pin sites, does not recall dark area, scab, or discoloration to top of right foot. LVN A said it is the CN's responsibility to collect new orders or office visit notes/progress notes when resident goes to outside appointments. LVN A said she tries to call to get notes or new orders when residents go to outside appointments but may not have time to follow up if not obtained. LVN A said that DON and/or ADON will follow up with outside appointments if aware. Interview on 03/13/2024 at 4:15 p.m. with orthopedic surgeon indicated that Resident #1 had been seen by orthopedic for several months due to fractured ankle, osteomyelitis, hardware failure/removal, and back in December 2023 resident had right ankle fusion with an external fixator device applied. Orthopedic surgeon denies that the use of Dakin's solution rather than hydrogen peroxide could have caused any damage or further skin impairment to Resident #1's external pin sites. The surgeon acknowledges that Resident #1 had upcoming surgery for external fixator pins to be exchanged. Interview on 03/13/2024 at 4:40 p.m. with LVN B, indicated that she cared for Resident #1, she was a CN nurse on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care and wrap RLE/external fixator with ace wrap during her shift. LVN said that resident had an external fixator/halo device to RLE and CN was responsible to provide pin site care every other day. LVN said that she did recall seeing a scab, or dark or discolored skin on top of resident's right foot but was not providing care or treatment to the area to her knowledge, no orders. LVN B said she has only been employed with the facility for about 1 month and follows her MAR/TAR to provide required treatments and medications. LVN B said that if residents go out to outside appointments that she thinks DON or ADON does follow up regarding new orders or treatments. LVN B said Resident #1 was cognitive and she could tell you what the doctor said. Interview on 03/13/2023 at 6:18 p.m. with Resident #1's FM indicated she went to the hospital ER to meet the resident on 02/27/2024. She stated she saw Resident #1 right lower extremity and told the ER staff that she had concerns regarding the care the resident was receiving at the current nursing facility. The FM stated she had redness and purulent drainage from her external fixator pin sites on right foot, a large black round wound to the top of her right foot, and a pressure sore to her right buttock. She stated she was in shock, the right foot looked horrible since she had last seen it at the orthopedic office on 02/14/2024. She stated the hospital diagnoses was infection at site of external fixator pin, cellulitis, and right foot wound. She stated the area on top of her right foot had dead tissue that had to be surgically removed and a graft placed. She said that the facility staff improper placement of ace wrap caused the wound on top of foot. FM said she was unaware of the pressure injury on right buttocks until she saw it at the hospital ER. FM said resident will not be returning to this facility due to the neglect and inadequate care provided to Resident #1. Interview on 03/14/2024 at 5:22 p.m. with RN C indicated that she works as the RN supervisor usually on weekends but does pick up days during the week if needed. RN C recalls Resident #1's right foot with external fixator device and CN had to provide pin site care using hydrogen peroxide and Q-tip every other day and then wrap RLE/external fixator with ace wrap for protection. RN C does not recall the last time she cared for Resident #1 and has no recollection of resident having any wounds or discolored area to of right foot or to right buttocks area that she assessed or provided care for. RN C said each resident was scheduled a day and shift for weekly skin assessments to be performed by CN. Skin assessment should identify any new wounds, skin tears, abrasions, lacerations, rash, skin impairment/damage, discoloration, bruises, pressure, diabetic, venous, arterial ulcer, or incisions. Interview on 03/18/2024 at 11:27 a.m. with LVN A acknowledges that she took the photographs of Resident #1's RLE and provided a copy to DON. LVN A reviewed the photo previously taken on 02/25/2024 and does identify a dark/discolored area to top of right foot. LVN A said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN A does not recall when the dark/discolored area on top of right foot occurred or was first identified. LVN A denies being notified by CNA that resident had a new skin impairment to right buttock. Interview on 03/18/2024 at 1:41 p.m. with DON G, said she was familiar with Resident #1, she said she had to do a write up/medication error on an LVN/CN because she used Dakin's solution for pin site care instead of hydrogen peroxide on 02/22/2024. DON G communicated with LVN A on 02/23/2024 regarding Resident #1's external fixator pin sites with redness and purulent drainage and told her to contact orthopedic surgeon with report. DON G said she received a text message and image/photo of Resident #1's RLE on 02/25/2024 with concerns that pin sites continue to have drainage and redness noted during wound care. DON G said on 02/26/2024 she contacted orthopedic surgeon's office for an earlier appointment and notified attending NP/MD. DON G said she forwarded the attending NP the photos she had received from LVN A and NP gave new orders for stat labs to be obtained. DON G said that she had not physically observed Resident #1's RLE, only the images sent to her. DON G said she reached out to the orthopedic surgeon several times trying to get resident an earlier appointment. DON G said that labs came back on 2/27/2024 indicating elevated white blood count and attending NP notified. She said attending NP consulted with orthopedic surgeon and resident was sent to affiliated hospital for evaluation and treatment. DON G does not recall facility staff mentioning Resident #1 having a dark/discolored area to top of foot but once she reviews the image/photo she acknowledges that image from 2/25/2024 does show a dark/discolored area to top of right foot. DON G said skin assessment should be performed weekly and as needed, DON G said areas like this should be documented and monitored. DON G said that she was no longer employed as the DON with this facility, was terminated at the end of February 2024. Interview on 03/20/2024 at 3:00 p.m. with CNA F, said she works 06:00 a.m. to 06:00 p.m. shift and provides personal care and assistance to residents. CNA F said she recalls Resdient#1 and her halo device to her right foot, she recalls that she reported to the CN once that the ace wrap had blood on it and pin sites appeared to be bleeding, she said CN assessed the right foot after reporting the incident. CNA F said she recalled providing care to Resident #1 days before or day of her being transferred to hospital, can't remember exact day, and when she place her hand on right hip area resident said ouch that hurt, CNA said she saw a fluid filled area to right hip/buttocks area, she completed her care and notified CN of her findings of fluid filled blister to right hip/buttocks area. CNA said I usually work with LVN B, but I cannot remember who I reported it to, but I remember reporting it to the CN. Interview on 03/20/2024 at 3:27 p.m. with LVN B, she acknowledges that the ace wrap being too tight could have caused the area to Resident #1's right dorsal foot, she said that she placed a non-adherent pad to area for protection at times. LVN B denies being notified by CNA that resident had a new skin impairment to right buttock. LVN B said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN B does not recall when the dark/discolored area on top of right foot occurred or was first identified. Interview on 03/14/2024 at 3:45 p.m. with DR E., who supervised NP D, he stated that he has seen Resident #1 with the external fixator and pin sites when he was visiting the roommate, approx. 1 week prior to hospitalization , while care was being provided to site, he does not recall seeing a dark/discolored area to top of right foot but says he was focus more on the pin sites which had a little redness but looked ok. DR E said that Resident #1 was seen by orthopedic surgeon routinely and he provided care/orders to RLE. DR E observed a photo of the RLE taken at the hospitalER on [DATE] and said no RLE did not look like that when he saw it, he said that NP D had been notified of the pin sites having drainage and redness on 02/26/2024 and she ordered labs and later consulted with orthopedic surgeon for hospital transfer and evaluation. DR E denied being notified or aware of dark/discolored area on top of right foot or fluid filled blister to right hip/buttocks area. Interview on 03/19/2024 at 8:00 a.m. with NP D indicated that she was notified by facility staff on 02/26/2024 that Resident #1 was having purulent drainage and redness at fixator pin sites, she ordered labs to be collected and for orthopedic appointment to be scheduled ASAP. NP D acknowledges that she received a picture of the Resident #1's RLE on 02/26/2024. NP D said that the focus at the time was the change in the pin site insertion sites, redness and purulent drainage, NP D reviews the photo provided to her on 02/26/2024 and does acknowledge the resident had a dark/discolored area to top of right foot but unable to access due to poor quality of picture. NP said that Resident #1 was routinely being seen by orthopedic doctor for care, interventions, and treatment to RLE. NP said Resident #1 was sent to affiliated hospital on 02/27/2024 due to abnormal lab values (elevated WBC count) and redness, and purulent drainage from fixator pin sites. Interview on 03/20/2024 at 12:05 p.m. with the ADON indicated initially Resident #1 admitted to facility with cast/splint due to fractured ankle, but due to hardware failure, resident had to have hardware removed and eternal fixator placed back in December 2023. ADON states that Resident #1 was seen by therapy services at first and has remained non-weight bearing. Resident #1 was being seen by orthopedic surgeon weekly, then biweekly then every three weeks. Resident #1 was non- weight bearing to RLE and facility staff was to provide pin site care to external fixator pins every other day using hydrogen peroxide and wrap RLE/external fixature with ace wraps. Resident was transported to orthopedic surgeon appointments and dialysis 3 x week by facility transport. ADON said that resident was cognitive and that she would report to facility what happened during her orthopedic appointments because family members would meet them at appointment and take office visit paperwork. ADON said that the charge nurse was responsible for following up when resident had outside appointment and getting the paperwork or new orders, ADON said that she or the DON was available to assist with getting office visit paperwork if needed assistance. ADON said that she contacted orthopedic surgeon for office visit notes for investigation related to medication error (staff applied wrong treatment to RLE pin sites) and had received and reviewed the documents on 02/29/2024. ADON said she had observed Resident #1's RLE with redness and purulent drainage to pin sites, recalls a dark/dried scab area to top of foot day prior to resident being transferred to hospital for evaluation. ADON said she also spoke with resident on 02/26/2024 regarding pin sites redness and drainage and resident said that orthopedic surgeon was aware of the pin sites redness and drainage during last orthopedic appointment and that they were scheduling surgery for pin sites to be exchanged. ADON denied that she contacted orthopedic surgeon to verify resident statement. ADON said that said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered if needed. Attempted to contact the Orthopedic Surgeon 03/20/2024 and 03/21/2024, office staff reports that he was in surgery on Thursday's mornings and would have return the call. No return call, called office multiple times and left message, no return call received from orthopedic surgeon. Interview on 03/21/2024 at 2:05 p.m. with the Administrator, she said Resident #1 had a scab on the top of her foot, but the focus was on her fixator pin sites. Administrator observed images from hospital ER assessment on 02/27/2024 and said that the wound on top of the right foot did not look like that at time of transfer to hospital ER. Administrator acknowledges that she did not observe the RLE prior to transfer to hospital ER but pictures or images she received days prior did not look like the hospital ER images. Administrator was aware that facility staff are not receiving or contacting outside appointment staff for office visit records or new orders and have put a new process in place that CN is to contact and obtain office visit notes and orders from outside appointments. The administrator said she has a PIP in place for skin assessments not being completed weekly. Resident # 1's skin assessment was completed weekly over the last month except for 02/26/2024 but the skin assessment did not indicate or acknowledge that resident had a dark/discolored area to top of right foot as identified in images/photos taken by facility and hospital staff. Administrator reluctantly agrees that a skin impairment (dark/discolored area, scab, redness) should be assessed and identified on weekly skin assessment and the orthopedic MD or attending physician should have been made aware for treatment plan or intervention. Record review of the facility policy and procedure titled Prevention of pressure injuries revised April 2020, indicated Skin Assessment 1. Conduct a comprehensive scan assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors and prior to discharge. 2. During the skin assessment, inspect a. presence of erythema; b. Temperature of skin and soft tissue; and c. edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.). Prevention Skin Care 4. Use a barrier product to prevent skin from moisture. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size shape and its application and ability to secure the device. 2. monitor regularly for comfort and signs of pressure related injury. The Administrator was notified of an Immediate Jeopardy (IJ) on 03/21/2024 at 5:09 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. 2. Record review of Resident #2's face sheet dated 01/30/24 indicated she was a [AGE] year-old female, initially admitted on [DATE], and her diagnoses included dementia (the impaired ability to remember, think, or make decisions that interferes with doing everyday activities), and high blood pressure. Resident #2 was readmitted on [DATE] with diagnosis of fracture of the femur (broken thigh bone). Record review of Physician orders for Resident #2 dated March 2024 indicated an order to elevate, off load right heel and monitor blister, report changes to MD with a start date of 2/2/24. Another order was to apply hydrogel to the right heel and cover with dry dressing daily with a start date of 3/22/24. Record review of Resident #2's admission MDS assessment dated [DATE] indicated she had severely impaired cognition with BIMS of 04. She was dependent on one staff for transfer and showers. Section M (skin): indicated no wounds, no issues with feet and no areas were noted. Record review of Resident #2's care plan dated 1/30/24 to 3/23/24 indicated on 3/23/24 there was an unstageable pressure ulcer on right heel with eschar (dead tissue), there was no mention of the blister on the right heel the resident admitted on [DATE]. Record review of Resident #2's admission assessment dated [DATE] at 6:52 p.m., indicated she was readmitted with a quarter size blister on her right heel that was covered with bandage from the hospital. The orders noted on 02/02/24 to elevate, offload right heel, and monitor blister and notify physician of any changes. Record review of weekly skin assessments for Resident #2 as follows: On 2/2/24, other: intact blister to right heel; offloading; On 2/9/24, other: intact blister to right heel; offloading; On 2/16/24, other: intact blister to right heel; offloading; On 2/23/24, other: N/A; On 3/1/24, other: N/A; On 03/08/24, other: N/A; and On 3/15/24, other: N/A. During an interview and observation on 3/23/24 at 10:40 a.m., MD E observed Resident #2's right heel and MD E said Resident #2 would need an appointment with wound care specialist for treatment. He said the facility notified him of the area yesterday (3/22/24). He said normally the facility would notify his nurse practitioner and receive orders to treat or referral to wound care. He said he was not told about the wound before 3/22/24. He stated, I will ask my Nurse Practitioner if she was aware of the wound. He said if the facility failed to notify him that failure could cause a delay in care. He said he felt responsible too. During an interview on 3/23/24 at 11:30 a.m., the NP D said she was not notified about Resident #2 having a blister on her right heel since readmission on 01/30/24 or having eschar on her right heel. She said the routine order for a blister would be to elevate, offload the heel, monitor the blister, and notify the physician of any changes. She said then on her next onsite visit, she would have assessed the area and order specific treatment, pain management, referral to wound care and make a progress note. During an interview on 3/23/24 at 12:30 p.m., The ADON said the weekly skin assessments for Resident #2 were not correct for 2/23/24 to 3/15/24 and should have included the blister on the right heel. She said there was no documentation of the physician being notified on the weekly skin assessments. Record review of podiatry note dated 2/21/24 indicated Resident #2 was seen and treated for trimming of the nails and no documentation about the blister. Record review of the nurse's note dated 03/16/24 indicated Resident #2 had a blister on right heel and was an unstageable wound do to wound was covered with eschar (a thick layer attached to the wound bed and often requires medical intervention from wound care specialist for debridement). There was no documentation of the physician being notified of Resident #2's blister on right heel had changed from a blister to eschar tissue on the right heel. The POR on 3/22/24 at 6:22 pm was accepted. Plan of Removal Problem: F686- Pressure Injuries Interventions: 1.DON/Designee will conduct a facility wide skin sweep to verify accuracy of documented wounds to be completed by 3/22/2024. 2.Registered Nurse consultant completed DON check off on staging and wound care 3/22/2024. 3.DON checked off registered nurses on wound staging and wound care on 3/22/2024. 4.DON initiated checked off on assessing and documenting changes in wounds and wound care with LVNs on 3/22/2024. Nurses will not be allowed to work the floor until education and in-service is completed. Education: 1.The following in-services were initiated by DON/designee on 3/21/2024: All available staff will begin being in-serviced on 3/21/2024, to be completed on or before 3/22/2024. Any staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in-serviced. 2. Administrator/designee to ensure that all in-service training has been done for all staff (nurses, CNAs, Medication Aides, dietary, housekeeping, and maintenance} by checking off the employee staff roster; tracking for completion of education and in servicing being completed by HR coordinator. All staff Change of Condition/Documenting the differentiation and identification of wounds. Nurses- In-service on wound care

Based on interview and record review , the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 10 residents reviewed for quality of care. The facility failed to coordinate care with the orthopedic surgeon and attending NP/MD of Resident #1's change in skin condition to RLE surgical area, addressing a scab, dark or discolored skin on top of resident's right foot identified in 02/14/2024. No documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or no coordination or communication with orthopedic surgeon or attending physician/NP regarding pressure injury/wound identified on 02/14/2024 by orthopedic surgeon. The facility failed to coordinate with orthopedic surgeon or attending NP/MD documented of right dorsal foot pressure injury when it deteriorated to an unstageable wound with eschar and resident had to be hospitalized and area required surgical debridement and graft application. An Immediate Jeopardy (IJ) was identified on 03/21/2024. The IJ template was provided to the facility on [DATE] at 5:09 p.m. While the IJ was removed on 03/23/2024 at 1:00 p.m., the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place. This failure could place residents at risk for diminished quality of care, untreated medical issues, and death. Findings included: Record review of Resident #1's electronic face sheet dated 03/13/2024 indicated she was originally admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included: displaced trimalleolar fracture of right lower leg (fracture of lower leg bone, connected to foot/ankle area), Other acute osteomyelitis (infection of the bone), left ankle and foot, Encounter for surgical aftercare following surgery on the skin and subcutaneous tissue-Right ankle ORIF (surgical procedure to replace bones with hardware or attach hardware to fix broken bone), Need for assistance with personal care, Muscle weakness (generalized), End stage renal disease ( a medical condition in which a person's kidneys cease functioning on a permanent basis leading to need for a regular course of long-term dialysis or a kidney transplant to maintain life), Cognitive communication deficit, metabolic encephalopathy ( another health condition, such as diabetes, liver disease, kidney failure, or heart failure, makes it hard for the brain to work), hypertension condition in which the force of the blood against the artery walls was too high, Diabetes mellitus (chronic condition that affects the way the body processes blood sugar). Record review of Resident #1's MDS dated [DATE] indicated she had no pressure injuries. She scored a 15/15 on her BIMS which signified she was cognitively intact. She was incontinent of bowel and bladder and went to dialysis 3 x week for hemodialysis for her end stage renal disease. She required substantial/maximal assistance with her ADL's. Record review of Resident #1's comprehensive care plan date initiated 12/15/2023 and revised on 03/01/2024 indicated Problem .has surgical wound to right ankle with pins in place .Approach . Assess condition of surrounding skin. Report emergence of skin excoriation. Observe and report signs of localized infection (localized pain, redness, swelling, tenderness, loss of function, heat at the infected area.) Further review indicated Problem . potential for impaired skin integrity related to impaired mobility. Approach . Assess feet Q shower day & PRN, noting color, peripheral pulses, sensory reflexes, temperature, presence of edema or verbalizations of pain. Assess skin weekly & PRN & document changes. Record review of Resident #1's Braden Skin assessment dated [DATE] indicated she scored a 19 which signified she was at a low risk for skin breakdown. The was no o current Braden Skin Assessment noted in medical records. Record review of Resident #1's Orders As of: 12/14/2023 to 02/27/2024 indicated: Treatments .to provide weekly skin assessment once a day on Monday 6:00 a.m. - 6:00 p.m. Dated 11/09/2023. Further review indicated Treatments . check skin surrounding splint to right leg. Check for capillaries refill to lower extremity every shift and as needed . Notify MD of any abnormalities or changes in skin condition. Every Shift: day shift 06:00 a.m. - 06:00 p.m., night shift 06:00 p.m. - 06:00 a.m. Dated 11/23/2023 Ended 02/26/2024. Wound Treatments: cleanse pin site to right ankle surgical site with peroxide once a day every other day 06:00 a.m. - 06:00 p.m. Dated 12/15/2023. Ended 02/27/2024. Record review of Resident #1's Skin - Dignity Weekly Skin assessment dated [DATE] authored by RN C indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Orthopedic progress note dated 02/14/2024 authored by orthopedic MD indicated that Resident #1 was being seen status post right ankle fusion with hardware removal with external fixator and pins placement on 12/11/2023. The external fixator frame was in place to RLE, swelling was mild, incision healed. Mild redness on the proximal medial and lateral pins. Abrasion with some black scabbing proximally 2 centimeters x 2 centimeters on the top of right foot. Record review of Resident #1's facility medical record dated 01/24/2024 to 02/25/2024 does not indicate facility was coordinating with orthopedic surgeon after follow-up visits provided. No orthopedic office visit notes identified in the medical records at the time of orthopedic office visits and no communication regarding continued treatment or orders noted from orthopedic office. Two orthopedic notes identified in the medical records were requested and received by facility on 02/29/2024 after the deterioration of RLE external pin site and black/dark area to top of right foot. Record review of Resident #1's Skin - Dignity Weekly Skin assessment dated [DATE] authored by LVN A indicated Resident #1 did not have a pressure, diabetic, venous, arterial ulcer, or incision. Other: Surgical incision with pins to the inner and outer right ankle, wound care in place. Record review of Resident #1's Skin - Dignity Weekly Skin Assessment due 02/26/2024 not found in medical records. Record review of Resident #1's progress notes from 02/14/2024 to 02/27/2024 revealed no documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or no coordination or communication with orthopedic surgeon or attending physician/NP regarding pressure injury/wound identified on 02/14/2024 by orthopedic surgeon. Record review of resident #1's TAR dated February 2024 did not have an assessment or treatment for pressure injury/wound on top of right foot. Record review of Resident #1's Progress Note dated 02/23/2024 authored by LVN A, indicated that CN was made aware by CNA that resident's right foot dressing had blood leaking. CN noted resident's right foot with dried blood on skin and pins, with white spots with clear drainage on side of foot too. CN cleaned wound per wound care order, DON, ADON, Administration, and MD notified of findings, no new orders given. Record review of Resident #1's Progress Note dated 02/25/2024 authored by LVN A, indicated that CN nurse cleaned residents' Right foot per wound care order, right foot had purulent drainage, with dried blood, RP notified, MD was already made aware upon first finding on 02/23/24. DON notified, ADON notified. Will monitor. Vital signs were within normal limits . Resident denies any pain or discomfort at this time. Record review of Resident #1's Progress Note dated 02/26/2024 authored by DON G indicates that the facility NP was notified regarding skin integrity and pictures were sent to NP. New orders for stat labs to be obtained and schedule an ortho visit as soon as possible . Record review of Resident #1's image of RLE dated 02/25/2024 and 02/26/2024 indicated that resident has a dark area to top of right foot with redness noted around wound. Record review of Resident #1's Progress Note dated 02/27/2024 authored by NP indicated that Resident #1 was seen today after having hemodialysis (a machine filters waste, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) session this morning. She continued to have drainage from RLE hardware x 5 days, the entry points in the heel, middle, and upper portions of the hardware have purulent drainage. She is complaining of significant pain. She has an appointment with Ortho scheduled for tomorrow, but labs from 02/26/2024 show leukocytosis of 17.9 which is concerning. Spoke with orthopedic MD on the phone and he advised transferring Resident #1 to affiliated hospital for evaluation. Record review of Resident #1's hospital record dated 02/27/2024, indicated Diagnosis: Chronic osteomyelitis (infection in the bone) of the right ankle, has external fixator, infection at sites of external fixator pins and right dorsal foot wound (pressure injury). Resident #1 underwent manipulation of external fixature, pin exchange and irrigation and debridement with application of integra graft to right dorsal foot (pressure injury site) on 02/29/2024. Skin head to toe assessment completed in hospital ER dated 02/27/2024 indicated Resident #1 was found to have pressure injury to right lateral buttock, measuring 2 cm x 2cm - images indicate site missing top layer of skin, pink in color, and a pressure injury to right dorsal foot measuring 2 cm x 4 cm - images indicate black/eschar tissue with redness around wound site. Plan: The patient has had some issues with the pin sites, we recommend surgery to evaluate exchange of pins. The resident was admitted for IV antibiotics, pain management and surgical intervention. Recommend compression of the ankle fusion through the frame as well as debridement of the dorsal midfoot wound that is worsening. Resident #1 underwent surgical intervention of right ankle manipulation of external fixator pin exchanged and wound irrigation, debridement, and graft application to right dorsal foot pressure injury/wound on 02/29/2024. Resident #1 was discharged on [DATE] to another nursing facility with orders to continue IV antibiotics for 8 weeks and to provide care to pressure injury/wound to right dorsal foot and pin sites daily and to follow up with infectious disease and orthopedic physicians. Interview on 03/13/2024 at 2:30 p.m. with LVN A, indicated that she cared for Resident #1, she was a CN nurse on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care, cleansed each site with hydrogen peroxide, and wrapped RLE/external fixator with ace wrap during her shift. LVN A said that Resident #1 had an external fixator/halo device to RLE status post hardware removal following ankle fracture and CN was responsible to provide pin site care every other day. LVN A said her pin sites started looking red, macerated, and purulent drainage on 02/23/2024 and reported the findings to DON, ADON, Administration, and MD notified of findings, no new orders given. LVN A does not recall assessing or providing treatment to an area on top of Resident #1's right foot. LVN A indicates that she took a photo of the resident's right lower extremity/foot and sent it to the DON due to her concerns with the external fixator pin sites. LVN A said the care provided and concerns was focused on the external fixators pin sites, does not recall scab, dark area, or discoloration to top of right foot. LVN A said it is the CN's responsibility to collect new orders or office visit notes/progress notes when resident goes to outside appointments. LVN A said she tries to call to get notes or new orders when residents go to outside appointments but may not have time to follow up if not obtained. LVN A said that DON and/or ADON will follow up with outside appointments if aware. Interview on 03/13/2024 at 4:40 p.m. with LVN B, indicated that she cared for Resident #1, she was a CN on 06:00 a.m. - 06:00 p.m. shift and she provided pin site care and wrap RLE/external fixator with ace wrap during her shift. LVN said that resident had an external fixator/halo device to RLE and CN was responsible to provide pin site care every other day. LVN said that she did recall seeing a dark or discolored skin on top of resident's right foot but was not providing care or treatment to the area to her knowledge, no orders. LVN B said she has only been employed with the facility for about 1 month and follows her MAR/TAR to provide required treatments and medications. LVN B said that if residents go out to outside appointments that she thinks DON or ADON does follow up regarding new orders or treatments. LVN B said Resident #1 was cognitive and she could tell you what the doctor said. Interview on 03/13/2023 at 6:18 p.m. with Resident #1's family member indicated she went to the hospital emergency room to meet the Resident #1 on 02/27/2024. She stated she saw Resident #1 right lower extremity and told the ER staff that she had concerns regarding the care the resident was receiving at the current nursing facility. The FM stated she had redness and purulent drainage from her external fixator pin sites on right foot, a large black round wound to the top of her right foot, and a pressure sore to her right buttock. She stated she was in shock, the right foot looked horrible since she had last seen it at the orthopedic office on 02/14/2024. She stated the hospital diagnoses was infection at site of external fixator pin, cellulitis, and right foot wound. She stated the area on top of her right foot had dead tissue that had to be surgically removed and a graft placed. She said that the facility staff improper placement of ace wrap caused the wound on top of foot. FM said she was unaware of the pressure injury on right buttocks until she saw it at the hospital ER. FM said resident will not be returning to this facility due to the neglect and inadequate care provided to Resident #1. Interview on 03/14/2024 at 5:22 p.m. with RN C indicated that she works as the RN supervisor usually on weekends but does pick up days during the week if needed. RN C recalls Resident #1's right foot with external fixator device and CN had to provide pin site care using hydrogen peroxide and Q-tip every other day and then wrap RLE/external fixator with ace wrap for protection. RN C does not recall the last time she cared for Resident #1 and has no recollection of resident having any wounds or discolored area to top of right foot area that she assessed or provided care for. RN C said each resident was scheduled a day and shift for weekly skin assessments to be performed by CN. Skin assessment should identify any new wounds, skin tears, abrasions, lacerations, rash, skin impairment/damage, discoloration, bruises, pressure, diabetic, venous, arterial ulcer, or incisions. Interview on 03/18/2024 at 11:27 a.m. with LVN A acknowledges that she took the photographs of Resident #1's RLE and provided a copy to DON. LVN A reviewed the photo previously taken on 02/25/2024 and does identify a dark/discolored area to top of right foot. LVN A said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN A does not recall when the dark/discolored area on top of right foot occurred or was first identified. Interview on 03/18/2024 at 1:41 p.m. with DON G, said she was familiar with Resident #1, she said she had to do a write up/medication error on an LVN because she used Dakin's solution (mixture of bleach or chlorine bleach, boric acid diluted in water) for pin site care instead of hydrogen peroxide on 02/22/2024. DON G communicated with LVN A on 02/23/2024 regarding Resident #1's external fixator pin sites with redness and purulent drainage and told her to contact orthopedic surgeon with report. DON G said she received a text message and image/photo of Resident #1's RLE on 02/25/2024 with concerns that pin sites continue to have drainage and redness noted during wound care. DON G said on 02/26/2024 she contacted orthopedic surgeon's office for an earlier appointment and notified attending NP/MD. DON G said she forwarded the attending NP the photos she had received from LVN A and NP gave new orders for stat labs to be obtained. DON G said that she had not physically observed Resident #1's RLE only the images sent to her. DON G said she reached out to orthopedic surgeon several times trying to get the resident an earlier appointment. DON G said that labs came back on 2/27/2024 indicating elevated white blood count and attending NP notified. She said attending NP consulted with orthopedic surgeon and resident was sent to affiliated hospital for evaluation and treatment. DON G does not recall facility staff mentioning Resident #1 having a dark/discolored area to top of foot but once she reviews the image/photo she acknowledges that image from 2/25/2024 does show a dark/discolored area to top of right foot. DON G said skin assessment should be performed weekly and as needed, DON G said areas like this should be documented and monitored. DON G said that she was no longer employed as the DON with this facility and was terminated at the end of February 2024. Interview on 03/20/2024 at 3:27 p.m. with LVN B, she acknowledges that the ace wrap being too tight could have caused the area to Resident #1's right dorsal foot, she said that she placed a non-adherent pad to area for protection at times. LVN B said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered. LVN B does not recall when the dark/discolored area on top of right foot occurred or was first identified. Interview on 03/14/2024 at 3:45 p.m. with DR E., who supervised NP D, he stated that he has seen Resident #1 with the external fixator and pin sites when he was visiting the roommate, approx. 1 week prior to hospitalization , while care was being provided to site, he does not recall seeing a dark/discolored area to top of right foot but says he was focus more on the pin sites which had a little redness but looked ok. DR E said that Resident #1 was seen by orthopedic surgeon routinely and he provided care/orders to RLE. DR E observed a photo of the RLE taken at the hospitalER on [DATE] and said no RLE did not look like that when he saw it, he said that NP D had been notified of the pin sites having drainage and redness on 02/26/2024 and she ordered labs and later consulted with orthopedic surgeon for hospital transfer and evaluation. DR E denied being notified or aware of dark/discolored area on top of right foot. Interview on 03/19/2024 at 8:00 a.m. with NP D indicated that she was notified by facility staff on 02/26/2024 that Resident #1 was having purulent drainage and redness at fixator pin sites, she ordered labs to be collected and for orthopedic appointment to be scheduled ASAP. NP D acknowledges that she received a picture of the Resident #1's RLE on 02/26/2024. NP D said that the focus at the time was the change in the pin site insertion sites, redness and purulent drainage, NP D reviews the photo provided to her on 02/26/2024 and does acknowledge the resident had a dark/discolored area to top of right foot but unable to assess due to poor quality of picture. NP said that Resident #1 was routinely being seen by orthopedic doctor for care, interventions, and treatment to RLE. NP said Resident #1 was sent to affiliated hospital on 02/27/2024 due to abnormal lab values (elevated WBC count) and redness, and purulent drainage from fixator pin sites. Interview on 03/20/2024 at 12:05 p.m. with the ADON indicated initially Resident #1 admitted to facility with cast/splint due to fractured ankle, but due to hardware failure, resident had to have hardware removed and eternal fixator placed back in December 2023. ADON states that Resident #1 was seen by therapy services at first and has remained non-weight bearing. Resident #1 was being seen by orthopedic surgeon weekly, then biweekly then every three weeks. Resident #1 was non- weight bearing to RLE and facility staff was to provide pin site care to external fixator pins every other day using hydrogen peroxide and wrap RLE/external fixature with ace wraps. Resident was transported to orthopedic surgeon appointments and dialysis 3 x week by facility transport. ADON said that resident was cognitive and that she would report to facility what happened during her orthopedic appointments because family members would meet them at appointment and take office visit paperwork. ADON said that the charge nurse was responsible for following up when resident had outside appointment and getting the paperwork or new orders, ADON said that she or the DON was available to assist with getting office visit paperwork if needed assistance. ADON said that she contacted orthopedic surgeon for office visit notes for investigation related to medication error (staff applied wrong treatment to RLE pin sites) and had received and reviewed the documents on 02/29/2024. ADON said she had observed Resident #1's RLE with redness and purulent drainage to pin sites, recalls a dark/dried scab area to top of foot day prior to resident being transferred to hospital for evaluation. ADON said she also spoke with resident on 02/26/2024 regarding pin sites redness and drainage and resident said that orthopedic surgeon was aware of the pin sites redness and drainage during last orthopedic appointment and that they were scheduling surgery for pin sites to be exchanged. ADON denied that she contacted orthopedic surgeon to verify resident statement. ADON said that said that the dark/discolored area on top of right foot should have been identified on the weekly skin assessments and the orthopedic MD or attending physician should have been made aware so assessment and treatment could have been ordered if needed. Attempted to contact the Orthopedic Surgeon 03/20/2024 and 03/21/2024, office staff reports that he was in surgery on Thursday mornings and he would return the call. No return call, called office multiple times and left message, no return call received from the Orthopedic Surgeon. Interview on 03/21/2024 at 2:05 p.m. with the Administrator, she said Resident #1 had a scab on the top of her foot, but the main focus was on her fixator pin sites. Administrator observed images from hospital ER assessment on 02/27/2024 and said that the wound on top of the right foot did not look like that at time of transfer to hospital ER. Administrator acknowledges that she did not observe the RLE prior to transfer to hospital ER but pictures or images she received days prior did not look like the hospital ER images. Administrator was aware that facility staff were not receiving or contacting outside appointment staff for office visit records or new orders and have put a new process in place that CN was to contact and obtain office visit notes and orders from outside appointments. The administrator said she has a perform improvement plan in place for skin assessments not being completed weekly. Resident # 1's skin assessment was completed weekly over the last month except for 02/26/2024 but the skin assessment did not indicate or acknowledge that resident had a dark/discolored area to top of right foot as identified in images/photos taken by facility and hospital staff. Administrator reluctantly agrees that a skin impairment (dark/discolored area, scab, redness) should be assessed and identified on weekly skin assessment and the orthopedic MD or attending physician should have been made aware for treatment plan or intervention. Record review of the facility policy and procedure titled Prevention of pressure injuries revised April 2020, indicated Skin Assessment 1. Conduct a comprehensive scan assessment upon (or soon after) admission, with each risk assessment as indicated according to the resident's risk factors and prior to discharge. 2. During the skin assessment, inspect a. presence of erythema; b. Temperature of skin and soft tissue; and c. edema. 3. Inspect the skin on a daily basis when performing or assisting with personal care or ADLs. a. Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; b. Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) . Prevention Skin Care 4. Use a barrier product to prevent skin from moisture. 6. Do not rub or otherwise cause friction on skin that is at risk of pressure injuries. Device-Related Pressure Injuries 1. Review and select medical devices with consideration to the ability to minimize tissue damage, including size shape and its application and ability to secure the device. 2. monitor regularly for comfort and signs of pressure related injury. The Administrator was notified of an Immediate Jeopardy on 03/21/2024 at 5:09 p.m. and was given a copy of the IJ template and a Plan of Removal (POR) was requested. The POR was accepted on 3/22/24 at 4:48 pm. Plan of Removal Problem: F684- Quality of Care Interventions: 1.DON/Designees will review all residents on resident roster to identify all residents receiving care from outside providers by 3/22/2024. 2.DON/Designees will provide updated clinical information to outside providers (MDs) on residents which pertain to their specific type of care; Ortho, cardiac, GI, urology, dental, podiatrist, etc. by 03/22/2024. DON/designee will pull information from residents' chart, including progress notes, all orders, medications, vital signs. This documentation will accompany the resident to their outside provider appointments. 3. The following in-services were initiated and conducted by Administrator and DON on 3/21/2024. All available staff will begin being in-serviced on 3/21/2024, to be completed on or before 3/22/2024. Any clinical staff member not present or in-serviced by this time will not be allowed to assume their duties until they have been in-serviced. Administrator/designee will ensure that all in-service training has been done for all clinical staff by checking off the clinical staff roster, check off being completed by HR coordinator. All clinical staff Care Coordination with all physicians involved in residents care and change of condition policy reviewed. CNA/CMA- Reporting changes in residents skin conditions when noticed immediately to charge nurse. Nurses-Assess and document changes in skin condition and notify MD. Outside providers shall also be notified if these changes pertain to the reason the resident in also in their care. When a resident returns from an appointment, the nurse will be responsible for ensuring she has received office visit notes and orders. The facility MD will be faxed/emailed this information to ensure he is also aware of the results of any outside office visits and changes/new orders. Should any outside providers see a resident on site at the facility, the nurse will review any notes and orders. These will be forwarded via fax/email to facility provider as well for his review. MOS- Care planning changes in resident's condition. DON/ADON- review 24- hour report for accuracy and care coordination follow-up. The POR was verified by interviews, and record reviews on 3/23/24 at 1:00 p.m. as follows: 4 LVNs and 2 MA and 6 CNAs interviews indicated the staff had been retrained on coordination of care on 3/22/24 and 3/23/24. During interviews with the Administer, DON, ADON indicated the resident's clinical charts were updated with all outside physicians and provided updated clinical information to all outside providers. The Administrator, DON, ADON indicated they were to monitor the 24-hour report for accuracy and care coordination follow-up. Interviews with 4 LVNs indicated they were retrained on the policy change of condition and coordination of care. The nurses were able to voice their role in assessing and document changes in skin condition and other changes in condition with the residents. Then they were to notify all physician involved with each resident's plan of care when a change of condition occurred. The 4 LVN were able to voice their role in coordination of care obtaining office visit notes and orders. The facility MD will be faxed/emailed this information to ensure he is also aware of the results of any outside office visits and changes/new orders. Should any outside providers see a resident on site at the facility, the nurse will obtain and review any notes and orders. These will be forwarded via fax/email to facility provider as well for his review. They said all change of conditions will also be documented on the 24 hour report, resident's clinical record and reported to DON and Administrator. Interviews with 2 MA indicated they were retrained on the policy of change of condition and were able to voice their role in notifying charge nurse, DON and Administrator of all changes of conditions with the residents. Interviews with 6 CNAs indicated they had been retrained and were able to voice what a change of condition was and how they were to report to charge nurse, DON and Administrator immediately. The CNAs said they were to document on stop and watch form and give the form to the charge nurse. Record reviews of the in-service records indicated training of staff was completed for the current staff on 3/23/24 and would be ongoing for any new staff (new staff or agency who had not been retrained) would be given prior to their first shift . The DON was monitoring and assuring the training record was updated after the staff was retrained and indicated the staff's responsibilities in coordination of care and notification to the physicians, nurses, and administration of the facility. Records review of 6 current residents indicated the clinical face sheet had been reviewed and updated as needed. No changes were noted for the 6 reviewed. All residents were assessed for any change of condition and a complete skin assessment was completed by RNs and 1 of the 6 residents had unstageable on her heel. The RN immediately reported to the physician and treatments were provided as ordered. The documentation indicated a coordination of care per notification of physician, nurse, and the facility administration. The care plan was updated, and the physician came to the facility and assessed the resident and ordered a referral and treatment. The primary physician was documenting on the wound and the referral orders. The referral for the wound care physician was being obtained and the charge nurses faxed needed items to the wound care physician. During an interview on 3/23/24 at 2:00 p.m., the DON said her expectations was for the nurses to notify her, ADON, Physician and the Administrator any new skin impairments/wounds and obtain treatment orders. She said all weekly skin assessments will be performed per the list at the nurse's station and followed up on as needed. On 03/23/24 at 1:00 p.m., the Administrator was informed the Immediate Jeopardy was lifted; however, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems that were put in place. [TRUNCATED]