Every finding on record at Decatur Medical Lodge

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety.The facility failed to ensure that only disposable paper towels were disposed of in the garbage receptacle at handwashing sink #1.The facility failed to ensure food items in the dry storage room were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards.The facility failed to ensure food items in the walk-in freezer were properly stored, sealed, and protected from exposure to air.These failures could place residents at risk for food-borne illness, cross contamination, and infection.During an observation of the #1 handwashing sink's garbage receptacle on 04/26/2026 at 9:54 a.m., the following was revealed:Handwashing sink #1 had a garbage receptacle that contained items other than disposable paper towels, including disposable gloves, a plastic lid, and a straw.During an interview on 04/26/2026 at 9:58 a.m., the Dietary Manager stated that the garbage receptacle at the #1 handwashing sink is used for paper towels and trash should not be thrown in the garbage receptacle.During an observation of the dry storage room on 04/26/2026 at 10:04 a.m., the following was revealed:2-gallon zipper storage bag with more than 10-round buns, opened date 04/25/2026 and use by date 04/28/2026 with no name and open to air.2-gallon zipper storage bag with 4 round buns, opened date 04/16/2026 and use by date 04/24/2026 with no name.1 can Tomato soup 50 oz, (3 lbs. 2 oz.), receive date 03/05/2026 use by date 01/19/2028 dented on top seal.1 can Mixed Vegetables 6 lbs. 8 oz., receive date 04/20/2026, no best by date, dent on lower left side.During an interview on 04/26/2026 at 10:22 a.m., the Dietary Manager stated that dates on the cans and zipper bags are the delivery date, open date, and use by date. If the product is not in its original packaging the product name should also be written on the bag. She said if residents were to eat food that is not properly sealed, they could become seriously ill. She said if there is no best buy date on the cans they go by the food labeling guide to determine the best by date.During an observation of the walk-in freezer on 04/26/2026 at 10:33 a.m., the following was revealed: 2-gallon zipper storage bag, rectangle bread or cheese sticks, opened date 04/25/2026, best by date 05/25/2026, no name on package. 2-gallon zipper storage bag, brown bag inside of zipped bag with opened date 04/13/2026, best by date 05/13/2026, no name on package.During an interview on 04/26/2026 at 10:41 a.m., the [NAME] stated that all staff were responsible for stocking food once delivered and any dented cans should be placed in the Dietary Manager's office. She added that the date received and the date opened were written on the product and if there was no 'best by' or 'use by' date, she used the food labeling guide. She said if residents consumed food that was not properly sealed, they could become seriously ill.During an interview on 04/26/2026 at 10:46 a.m., the Dietary Manager stated that she was primarily responsible for stocking food once it arrived. She noted that any can with a dent on the seam, regardless of size, was always placed in the designated dented can area in her office. She also stated that all freezer items were required to have both an open date and a use by date, and if a product was not in its original packaging, it needed to be labeled with its name. In a record review of the facility's Food Receiving and Storage, dated July 2014, revealed, 7. All foods stored in the refrigerator or freezer will be covered, labeled and dated ( use by date). There is no mention of the appearance of cans. Review of the U.S. FDA Food Code 2022, Chapter 3, 3-202.15 revealed, Damaged or incorrectly applied packaging may allow the entry of bacteria or other contaminants into the contained food. If the integrity of the packaging has been compromised, contaminants.may find their way into the food.Review of the U.S. FDA Food Code 2022 revealed, Section 6-301.20 Disposable Towels, Waste Receptacle. Waste Receptacles at handwashing sinks are required for the collection of disposable towels so that the paper waste will be contained, will not contact food directly or indirectly, and will not become an attractant for insects or rodents.

Based on observations, interviews, and record reviews the facility failed to ensure that based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility provided the necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for two (Resident #96 and Resident #34) of 5 residents, reviewed for positioning during meals. The facility failed to ensure CNA A correctly positioned Resident #96 for feeding. The facility failed to ensure CNA E correctly positioned Resident #34 for feeding. This failure placed residents at risk for aspiration and choking due to poor positioning while eating. Findings included: Review of Resident #96's Quarterly MDS Assessment, dated 04/02/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. Her diagnoses included stroke, non-Alzheimer's dementia, and Parkinson's disease. The resident was on a mechanically altered diet. Review of Resident #96's Order Summary Report dated 09/01/23, reflected:Regular diet, mechanical soft texture, regular/thin consistency. Review of Resident #96's Comprehensive Care Plans, dated 10/23/24, reflected the resident had an ADL self-care performance deficitFacility interventions included:Eating: Resident was totally dependent on staff for assistance with eating. In an observation on 04/26/26 at 12:50 PM, CNA A fed Resident #96 two bites of her pureed food while the resident was reclined in a geri-chair. The resident did not cough or show symptoms of choking. In an interview on 04/26/26 at 12:55 PM, CNA A said she was feeding the resident in a reclined position because the family wanted the geri-chair to remain reclined. CNA A said the resident was at risk of choking but had never choked before. CNA A said she was trained to position residents for feeding. CNA A asked the Surveyor what she should do. ADON C walked over to Resident #96. ADON C said the resident was supposed to be fed in a reclined position because the family wanted the geri-chair to remain reclined. ADON C said the charge nurse was responsible for ensuring residents were in a correct position to eat. ADON C did say the reclined position to eat could cause aspiration, and choking. ADON C walked away. CNA B walked over and told CNA A to assist him to reposition Resident #96. They were able to sit her in a more upright position. The resident was able to lean forward to eat and drink without issue. In an interview on 04/26/26 at 1:00 PM, LVN D was in the dining room. She said she was an agency nurse and assisted staff to help ensure residents were in the correct position to eat. LVN D said she was not familiar with Resident #96. LVN D said the resident was at risk for aspiration and choking if she was fed in a reclined position. In an interview on 04/26/26 at 1:10 PM, the DON said Resident #96's family was finicky and wanted the resident to stay reclined to eat. The DON said the resident was at risk of choking if fed in a reclined position. The DON said Resident #96 had never choked during eating and staff had been trained how to position residents to correctly feed them. The DON said it was a team effort to ensure residents were correctly positioned to eat. In an interview on 04/26/26 at 1:15 PM, the family representative of Resident #96 said she never told facility staff to recline the resident to eat. She said she expected the facility to know to sit the resident upright to eat. Review of Resident #34's Quarterly MDS Assessment, dated 01/22/26, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. Her cognitive skills for daily decision making were severely impaired. Her diagnoses included stroke, heart failure, and non-Alzheimer's disease. The resident was on a mechanically altered diet. Review of Resident #34's Order Summary Report, dated 07/08/25, reflected:No added salt diet, pureed texture, nectar thick consistency. Review of Resident #34's Comprehensive Care Plans, dated 07/03/25, reflected the resident had an ADL self-care performance deficit related to right upper extremity hand contracture.Facility interventions included:Eating: Resident required extensive assistance with eating. In an observation and interview on 04/27/26 at 12:50 PM, CNA E was feeding Resident #34. Resident #34 had her neck and head bent over to the left side. CNA E was holding the drinking glass, and the resident was drinking fluids. CNA E said Resident #34 would normally lean over to eat and drink but that did place her at risk for choking. CNA E stood up and repositioned the resident to an upright position. CNA E said she had not been trained to position the resident to eat. ADON Z walked into the dining room and over to the resident. ADON Z said the resident was not supposed to lean over to her left side to eat. In an interview on 04/27/26 at 1:00 pm, the DON said CNA E was trained to position residents correctly and Resident #34 was supposed to sit upright to eat. The DON said the resident did not have any coughing or choking incidents. The DON said administrative staff would make rounds in the dining room and watch for positioning. Record review of the facility policy, Assistance with Meals, revised 02/09/24, reflected: Residents shall receive assistance with meals in a manner that meets the individual needs of the resident.

Based on interviews and record reviews, the facility failed to notify the resident and/or resident's representative(s) in writing of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 2 (Resident #14 and Resident #109) of 6 residents reviewed for discharge planning. The facility failed to notify the residents or the residents' representative or POA of the transfer or discharge with the reasons for the move in writing in a language and manner they understand for Resident #14 and Resident #109.The facility failed to send a copy of the notice of transfer or discharge to the representative of the Office of the State LTC Ombudsman involving Resident #14 and Resident #109These failures could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services. A record review of Resident #14's face sheet, dated 04/27/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE]. Her diagnoses included Cognitive Communication deficit (often caused by brain injury (stroke, tumor, TBI) or neurological disease), Dysphagia (difficulty swallowing), Atherosclerotic heart disease of native coronary artery without angina pectoris (where plaque builds up in the heart's original arteries without causing chest pain), and Acute embolism and thrombosis of the right peroneal vein (blood clot in the deep veins of the calf). Her face sheet also revealed her family member was her responsible party and emergency contact.A record review of Resident #14's MDS, dated [DATE], reflected a BIMS score of 03/15, indicated severe cognitive impairment. Resident #14 required substantial to maximal assistance (which meant staff did more than half the effort) with care.A record review of Resident #14's progress note dated 03/11/2026, revealed Resident #14 was sent to the ER, due to stomach pain, unable to open her eyes, and elevated anion gap (indicates high levels of acid in the blood). There was no evidence that a transfer or discharge notice had been provided to Resident #14 or her responsible party in writing or to the LTC Ombudsman. In an interview on 04/27/2026 at 2:05 p.m., Resident #14 revealed she had never received a written letter when she was sent to the emergency room, but her family member might have received it.An attempt to contact her responsible party on 04/27/2026 at 2:48 p.m., was unsuccessful.2. A record review of Resident #109's face sheet, dated 04/28/2026, revealed the resident was a [AGE] year-old female initially admitted to the facility on [DATE] and her family member was her responsible party. Her diagnoses included Unspecified atrial fibrillation (an irregular, often rapid heart rate where the upper chambers quiver), Dementia (a decline in memory, thinking, and behavioral abilities severe enough to disrupt daily life), Muscle Weakness (reduced ability to exert force with muscles, often caused by nerve damage or disuse), Essential Hypertension (chronic, high blood pressure), and Atherosclerotic heart disease of native coronary artery without angina pectoris (where plaque builds up in the heart's original arteries without causing chest pain).A record review of Resident #109's MDS, dated [DATE], reflected a BIMS score of 03/15, indicated severe cognitive impairment. Resident #109 required substantial to maximal assistance (which meant staff does more than half the effort) with care.A record review of Resident #109's progress note dated 12/23/2025, revealed Resident #14 was sent to the ER, due to altered level of consciousness and general weakness. There was no evidence that a transfer or discharge notice had been provided to Resident #109 or to her responsible party in writing or to the LTC Ombudsman. In an interview on 04/10/2026 at 1:01 p.m., Resident #109's family member revealed he had never received a written letter when Resident #109 was sent to the emergency room. During an interview on 04/27/2026 at 2:19 p.m., Social Worker revealed that she did not provide a written notice to the resident or the resident's responsible party when a resident was transferred to the emergency room. She explained that the nurses notified the responsible party by telephone at the time of the transfer. She said she sends a list of names to the Ombudsman monthly.During an interview on 04/27/2026 at 2:41 p.m., the DON revealed that she did not provide written notices or letters to residents or their responsible parties when residents were transferred to the emergency room. She explained that she and the nursing staff notified the responsible party by telephone at the time of the transfer. She said she did not see a negative impact on the residents because they did not receive a transfer or discharge notice in writing, because the nurses have conversations with the residents about the reason the went to the hospital when they return to the facility.During an interview on 04/28/2026 at 12:36 p.m., the Ombudsman revealed the only discharges she's received from this facility were from March 2026 and on April 3, 2026, she received one.During an interview on 04/28/2026 at 1:53 p.m., the Administrator revealed that the facility did not provide written notices of transfer or discharge to residents or their responsible parties when a resident was sent to the emergency room. He explained that residents were informed verbally of the transfer, and responsible parties were notified by telephone at the time of the transfer. The Administrator further revealed that a discharge notice was only provided to residents when they returned to their home or transferred to another facility. In a record review of the facility's Transfer or Discharge, Emergency policy, with an unknown date, revealed: .3. Should it become necessary to make an emergency transfer or discharge to a hospital or other related institution, our facility will implement the following procedures: a. Notify the resident's Attending Physician; b. Notify the receiving facility that the transfer is being made; c. Prepare the resident for transfer; d. Prepare a transfer form to send with the resident;e. Notify the representative (sponsor) or other family member;f. Assist in obtaining transportation; and g. Others as appropriate or as necessary.References OBRA Regulatory Reference Numbers S483.15(c) Transfer and dischargeIn a record review of Regulation S483.15(c)(3) states Notice before transfer. Before a facility transfers or discharges a resident, the facility must-(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and(iii) Include in the notice the items described in paragraph (c)(5) of this section.S483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge;(ii) The effective date of transfer or discharge;(iii) The location to which the resident is transferred or discharged ;(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman.(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and [NAME] of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

Based on observations, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for one (Resident #63) of 8 residents, reviewed for puree' meals. The facility failed to ensure [NAME] F correctly prepared a puree' meal for Resident #63. This failure placed residents at risk for aspiration and choking due to food not being prepared correctly.Findings included: Review of Resident #63's Quarterly MDS Assessment, dated 03/05/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 6 indicating her cognitive skills were severely impaired. Her diagnoses included stroke, seizure disorder, and malnutrition. The resident was on a therapeutic diet. Review of Resident #63's Order Summary Report dated 04/10/26, reflected:Pureed texture, regular consistency diet Review of Resident #63's Comprehensive Care Plans, dated 11/03/25, reflected:Nutritional problem or potential nutritional problem.At risk for malnutrition.Facility interventions included:Provide and serve diet as ordered. An observation on 04/27/26 at 1:30 PM revealed the facility provided a sample tray. The puree' food was tamales, stewed tomatoes, charro beans, rolls, Spanish rice, and a sopapilla. The taste test of the food by the Surveyor revealed there was shredded corn husk in the puree' tamales. The puree' tamales were not edible because the corn husk could not be chewed and had to be spit out by the Surveyor. In an interview on 04/27/26 at 1:35 PM, the Dietary Manager entered the conference room. The Dietary Manager took a bite of the puree' tamale and said, The husk is in there. The Dietary Manager spit out the husk and said, I need to go check on the residents right now. In an interview on 04/27/26 at 3:10 PM, CNA G said she fed Resident #63 the puree' tamales. CNA G said the puree' tamales had some pieces sticking out of it. CNA G said, I had to pull those pieces out and just give her the puree' pieces. CNA G said the resident did not have any coughing, choking, and did not spit the food out. In an interview on 04/27/26 at 3:20 PM, the DON said she did not see any of the lunch trays. The DON said if any of the residents ate the puree' food with the corn husks, it could result in difficulty swallowing. The DON said she assessed all eight residents who were served the puree' lunch meal and none of the residents had any issues after the meal. The DON said the nurses were responsible for checking the trays and dietary staff in the kitchen had to check the trays for consistency. The DON said this incident never happened before and she did not know why it happened on 04/27/26. In an interview on 04/27/26 at 3:30 PM, Dietary Manager said [NAME] F prepared the puree' tamales. She said [NAME] F usually did a great job with her textures. The Dietary Manager said [NAME] F was supposed to taste the food she prepared, but at the end of the day, the Dietary manager was responsible for ensuring food was the correct texture. The Dietary Manager said the puree' food was supposed to be tasted every meal, but she did not taste the puree' tamales for the lunch meal. The Dietary Manager said wrong textures served to residents placed them at high risk and could lead to potential hospitalization. In an interview on 04/27/26 3:35 pm, LVN H said she checked the lunch trays. She said she did not see anything wrong with the puree' trays. In an interview on 04/28/2026 at 1:13 PM, [NAME] F said she had worked at the facility for almost four years. She said she prepared the puree' tamales and had been trained to puree' food. [NAME] F said she would normally taste the food she prepared but did not taste the food at lunch. She said she was in too much of a hurry. [NAME] F said she thought she removed the corn husks from the tamales and did not know how a corn husk ended up in the puree' food. [NAME] F said residents could have a hard time swallowing the food if it was not pureed correctly. Record review of the facility policy, Puree Food Summary, not dated, reflected: Mechanically altered foods are important for those with:Dysphagia - decrease in swallowing ability.

Based on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment one (Resident #2) of 4 residents, reviewed for PASARR. The facility failed to ensure the MDS Coordinator referred Resident #2 for a PASARR evaluation or PASARR Level 2 screening. This failure placed residents at risk of not receiving PASARR services they could potentially receive.Findings included: Record review of Resident #2's Annual MDS Assessment, dated 02/26/26, reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His BIMS score was 11 indicating his cognitive skills were moderately impaired. His diagnoses included post-traumatic stress disorder, anxiety disorder and depression. Record review of Resident #2's Comprehensive Care Plans, dated 03/27/25, reflected:At risk for a mood problem related to post-traumatic stress disorder.Facility interventions included:Behavioral health consults as needed. Record review of Resident #2's PASARR Level 1 screening, dated 12/26/24, reflected he did not have any mental disorders. Record review of Resident #2's clinical record reflected he did not have a PASARR Level 2 screening or a PASARR Evaluation. In an interview on 04/26/26 at 11:05 am, Resident #2 said he did not receive PASARR services. In an interview on 04/28/26 at 10:31 AM, the MDS Coordinator said the resident was a veteran and did not qualify for PASARR services. The MDS Coordinator said the resident had a negative PASARR Level 1 and it was not correct based on the resident's diagnosis. The MDS Coordinator said she missed the diagnosis and did not submit a new PASARR Level 1 screening. The MDS Coordinator said a negative PASARR Level 1 screening could cause residents to miss PASARR services. The facility policy for PASARR services was requested on 04/28/26 at 1:01 PM from the Administrator and DON. The policy was not received prior to exit on 04/28/26.

Based on observation, interview, and record review, the facility to ensure each resident received adequate supervision and assistance devices to prevent accidents for residents for 1 (Resident #13) of 5 residents reviewed for devices. The facility failed to maintain Resident #13's manual wheelchair, which was missing the right-hand armrest and had a cracked and worn left armrest, exposing he resident to possible skin breakdown. This failure could place residents at risk of being uncomfortable and of injury from equipment not properly maintained.Findings included:Record review of Resident #13's Face Sheet, dated 04/27/2026, reflected Resident #13 was a [AGE] year-old male, admitted on [DATE], with diagnoses that included Hemiplegia and Hemiparesis following Cerebral Infarction affecting Left Non-Dominant Side (paralysis of the left side after a stroke), End Stage Renal Disease (kidney failure), and Unspecified Convulsions.Record review of Resident #13's Comprehensive MDS, dated [DATE], reflected a BIMS Score of 05 indicating severe cognitive impairment. Section GG-Functional Abilities reflected Resident #13 required a wheelchair and was completely dependent for toileting and showering. Section M-Skin Conditions reflected Resident #13 was at risk of developing Pressure Ulcers.Record review of Resident #13's Comprehensive Care Plan, dated 04/08/2026, indicated that under Focus: [Resident #13] had a behavioral problem (picking at skin causing wounds). Goal: [Resident #13] will have fewer episodes through review date. Interventions: Anticipate and meet the resident's needs. Explain all procedures to the resident before starting and allow resident to adjust to changes. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Focus: [Resident #13] is on anticonvulsants therapy. Goal: [Resident #13] will be free of any discomfort or adverse side effects of anticonvulsants therapy through review date' Interventions: Observe and report any seizure activity. Focus: [Resident #13] is on antiplatelet therapy disease process. Goal: [Resident #13 will be free from adverse reactions related to antiplatelet therapy through next review. Interventions: Skin inspections as needed and report changes or increase in bruising.During an observation and interview on 04/26/26 at 12:35 p.m. in the dining room, Resident #13 was seated in a wheelchair at a dining table. Resident #13's wheelchair was noted to be missing an armrest cushion on the resident's right side and the armrest on Resident #13's left side was observed to be cracked, had open areas exposing the cushion-filling underneath and appeared to be missing some of the cushion filling. Resident #13 was noted to have several scabs on both forearms. Resident #13 stated that he was not sure where the scabs on his arms came from. He stated that he would like to have an armrest on the right side of his wheelchair and on the left side of his wheelchair. He stated that he had told his family about the missing armrest. During an interview on 04/27/26 at 1:40 PM, Resident #13's Resident Representative was interviewed in Resident #13's room. She stated she would like to see Resident #13's wheelchair repaired. She stated she believed Resident #13 mentioned the missing armrest to the staff at the facility [she was unable to identify which staff]. She stated that she thought it might be uncomfortable to not have an armrest on the right side of the wheelchair, and it could possibly cause scratches or bruising. During an interview on 04/27/2026 at 1:40 PM, the DOR stated all of the wheelchairs in the facility were owned by the facility and rehabilitation was not responsible for the wheelchairs, but her staff would notify the facility if a wheelchair needed repairs.During an interview on 04/27/2026 at 2:13 PM, CNA E stated she had not seen any wheelchairs that needed to have armrests repaired or replaced. She stated if she had seen wheelchairs that needed repair, she would report it to the nurse. She stated there was not a physical logbook but knew there was an electronic way to notify the Maintenance Manager of equipment that needed repair. She further stated that not having wheelchair armrests could cause skin breakdown.During an interview on 04/28/2026 at 11:11 AM, the DON said t skin breakdown could occur on the arms of a resident if the armrest was missing or cracked. She stated the process for maintaining maintenance on wheelchairs would be started by ADON to go through all resident equipment to make sure equipment stayed in good repair. She stated maintenance issues were reported through an electronic interface that all CNAs and nurses had access to.During an interview on 04/28/2026 at 12:29 PM, the Maintenance Manager said the staff used an electronic interface to communicate equipment in the facility to be repaired. He stated he was not aware of any repairs that were needed for Resident #13's wheelchair. Record review of a facility policy titled, Equipment Maintenance, dated September 2005 and updated June 2019 revealed 3. all resident equipment supplied by the facility will be maintained.

Based on observations, interviews, and record reviews, 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 one (Resident #86) of 5 residents, reviewed for infection control. The facility failed to ensure CNA I performed hand hygiene during incontinence care for Resident #86. This failure placed residents at risk for infection due to not performing hand hygiene.Findings included: Review of Resident #86's Quarterly MDS Assessment, dated 04/01/26, reflected the resident was an [AGE] year-old female admitted to the facility on [DATE]. Her BIMS score was 7 indicating her cognitive skills were severely impaired. Her diagnoses included heart failure and non-Alzheimer's dementia. Review of Resident #86's Comprehensive Care Plans, dated 02/26/26, reflected:ADL self-care performance deficit related to muscle weakness.Facility interventions included:Toilet use: Resident required extensive assistance from one staff with toiletuse. In an observation on 04/27/26 at 10:00 AM, CNA I was preparing to perform incontinence care for Resident #86. CNA I cleaned the resident and removed the soiled brief. CNA I changed gloves and did not perform hand hygiene. CNA I placed a clean brief on the resident. In an interview on 04/27/26 at 10:05 AM, CNA I said she was supposed to perform hand hygiene when she changed gloves. She said she did not do the hand hygiene this time but was trained too. CNA I said the resident was at risk for the spread of germs if hand hygiene was not performed. In an interview on 04/28/26 at 10:47 AM, the DON said staff were supposed to perform hand hygiene when they changed gloves and had been trained to do it. The DON said monitoring was in place and management observed staff for hand hygiene and educated staff frequently. The DON said residents were at risk for the spread of infection if hand hygiene was not performed. Record review of the facility policy, Hand Washing/Hand Hygiene, revised 12/22/23, reflected: The facility considers hand hygiene the primary means to prevent the spread of infections.7. Use an alcohol-based hand rub.or alternatively, soap. and water for the following situations.m. After removing gloves.

Based on observation, interview and record review the facility failed to ensure residents received and were provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for two of two residents (Resident #1 and #2) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature and taste to Residents #1 and #2. This failure could place residents at risk of weight loss, altered nutritional, status, and diminished quality of life. Findings include: 1. Record review of Resident #1's, undated, admission Record revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #1 had a diagnosis which included Parkinson's Disease without dyskinesia, without mention of fluctuations (A neurodegenerative disease primarily affecting the central nervous system affecting both motor and non-motor systems but without the writhing/wriggling/dramatic movements or fluctuations). Record review of Resident #1's Care Plan, dated 12/05/2023, revealed; Focus; Resident #1 had nutritional problem or potential nutritional problem related to diet restrictions, heart Disease, Hypothyroidism (when the thyroid gland doesn't make enough thyroid hormone), Depression and Medications. Goal: Resident #1 would not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output. Diabetes, impaired mobility. Interventions; Monitor/record/report to MD PRN s/sx of malnutrition: Emaciation (Cachexia) (this refers to the end stage of emaciation which is an involuntary wasting disorder, marked by significant weight loss); muscle wasting, significant weight loss; 3lbs in 1 week, >5% in 1 month, >7.5 in 1 month, >7.5% in 3 months, >10% in 6 months. Record review of MDS assessment, dated 05/15/2025, revealed; Resident #1 had a BIMS score of 9, which indicated moderate cognitive impairment. Section G- Functional Status ; Section H; Eating- Resident #1 required Supervision-oversight, encouragement to eat. 2. Record review of Resident #2's, undated, admission record revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #2 had a primary diagnosis which included other nondisplaced fracture of fifth cervical vertebra, subsequent encounter for fracture with routine healing encounter for other specified surgical aftercare Record review of Resident #2's Care Plan, dated 06/02/2025, revealed Resident #2 Focus: ADL self-care performance deficit r/t nondisplaced fracture to the 5th cervical vertebrae. Intervention: eating. Resident #2 required supervision and set-up assistance with eating. During an observation on 06/25/2025 at 12:06 PM in the facility's only dining room revealed 37 residents assembled at multiple tables waiting for lunch service. During an observation on 06/25/2025 at 12:13 PM in the facility's only dining room revealed the first tray was served. At 12:43 PM revealed all residents in the dining room were served a lunch tray. During an observation and interview on 06/25/2025 at 12:50 PM with Resident #2 revealed Resident #2 sitting in his manual wheelchair inside his room. He stated I wish I could get lunch on time it is close to 1:00PM. I think the cook use to work at a 'prison' because the way the food looks. He stated he did not receive condiments with his food and most of the time it is cold by the time I get it. During an observation on 06/25/2025 revealed the following: 12:59 PM- Hall 100 meal trays delivered on tray cart 1:10 PM-Hall 200 meal trays delivered on tray cart 1:18 PM- Hall 300 meal trays delivered on tray cart 1:33 PM-Hall 400 meal trays delivered on tray cart During an observation on 06/25/2025 at 1:13 PM, in the facility dining room revealed; place settings with five bowls of uneaten tomato soup and one bowl with less than 25% of tomato soup eaten. Single serving container of ice cream 100% eaten. Several packets of saltines, which were unopened. Next to the food items was a meal ticket with Resident #1's name printed at the top handwritten in area labeled Special Notes: 2 tomato soup, Ice cream. Observation on 06/25/2025 at 1:24 PM revealed LVN A carried a lunch tray to Resident #2's room. Observation of Mealtimes revealed it was posted in the facility dining room Breakfast: 7:00 am- 8:45 AM; Lunch: 12:00pm-1:15 PM; Supper 5:00pm-6:15PM. During an interview on 06/25/2025 at 11:34 AM the State Surveyors requested DM provide a sample tray with regular texture meal items, same portions and resident set up. The sample tray will be the last tray served . During an interview on 06/25/2025 at 1:11 PM with Resident #1 revealed; out of six bowls of tomato soup they could not get it right they were all cold. He just ate crackers and ice cream for lunch. Interview on 06/25/2025 at 1:24 PM with LVN A revealed she was told to take Resident #2 his lunch tray prior to 400 hall trays being delivered. She stated this was not routine, but she did what she was told to do. She stated residents expected to receive their meals at a certain time. She stated the risk of not receiving lunch on time could result in tensions flaring up and residents getting upset. Interview on 06/25/2025 at 1:28 PM with Resident #2 revealed the lunch tray was on the bedside table positioned across the resident. He received a regular texture food tray. He stated his food looked pleasant and appeared palatable. He stated it did not always look palatable. When asked if he received everything, he needed to enjoy his meal he stated the only thing missing was salt and pepper. Observation and interview on 06/25/2025 at 1:38 PM with the DM and Kitchen Supervisor revealed the sample tray was delivered to conference room by both staff members. The food appeared visually appetizing. Temperatures were taken with facility thermometer by the Kitchen Supervisor. Pork Chop - 150 Seasoned Broccoli 115 Red Beans 141 The DM stated lunch was delayed because the dining room meal tickets were not organized. He stated the kitchen microwave was not working properly during lunch and they were unable to heat items. He stated he notified maintenance to repair the microwave. The Kitchen Supervisor stated the sample tray was missing salt and pepper; the risk was residents could not season food to taste and enjoyment . Interview on 06/25/2025 at 2:53 PM with Maintenance Director revealed he was called to the kitchen during lunch time because the microwave was not working. He stated the microwave was working properly but someone messed with the settings and it was not heating the food. He stated he pushed the settings buttons then put a test plate into the microwave and it worked properly . Interview on 06/25/2025 at 3:38 PM with the DON revealed residents should be happy with their food. She stated the DM started on Monday (06/23/2025) and we must develop a system that works on both sides. She stated Resident #2 voiced prior dining concerns that he would like more gravy on his potatoes and double portions. Resident #1 asked for his soup to be hotter. She stated Resident #1 hadn't expressed prior dietary issues. She stated she wanted them to have a meal that made them happy, and they enjoyed. Interview on 06/25/2025 at 4:00 PM with LVN B revealed she was in the dining room during lunch when Resident #1 stated his soup was cold and asked if he could get another order of soup at a temperature he would enjoy. She stated she stirred the soup with a spoon, and it appeared thick like it was cold and not thin when it was warm. She stated she told the kitchen staff, and they prepared two more bowls of soup. She delivered the second bowls of soup to Resident #1. again he stated the soup was cold. She stated she informed the kitchen staff the resident again said the soup was cold. The kitchen staff informed her they thought it was the microwave. The third round of soup was taken to the resident; she stated it appeared to have steam coming from the soup. She stated the bowl felt warmer. She stated after the third attempt Resident #1 declined additional soup. She stated residents should receive food they could eat and enjoy; this was their home. The risk was resident's would not eat and that would put them in a bad mood, you have to eat and get nutrition. The LVN B stated she felt bad there was a risk he would not get his adequate intake . Interview on 06/25/2025 at 4:32 PM with Resident #1 revealed he stated he was disappointed because he really liked tomato soup. He stated he would be okay until dinner and declined the offer to get another lunch tray . Interview on 06/25/2025 at 4:45 PM with the ADMIN revealed the facility wanted the residents to enjoy their meals; hot foods should be served hot and cold foods should be served cold. Residents should receive everything with their meal which included salt and pepper that was important to all of us. The risk was dissatisfaction, and residents tended not to eat; had weight loss and not well nourished could affect the body. Record review of the Food Temperature Log, dated 06/25, revealed no entry for soup. Record review of Work Orders, dated 06/25/2025, revealed; Summary- Microwave not working. Record review of [The Facility] Resident Council dated May 13, 2025, revealed; 1. Dietary: Resident council resident stated oatmeal tastes funny and scrambled eggs are not creamy. Resident council resident stated they can't get her order right and breakfast was cold (06/12/2025). Resident council resident stated her food is cold . Record review of [The Facility] Resident Council Responses, dated 05/13/2025, revealed talked to cook about not putting anything in oatmeal and make sure eggs are prepared right for residents. Talked to staff about getting order right and make sure food goes to room quickly. Talked to staff about getting food out quickly. Record review of [The Facility] Resident Council, dated June 12, 2025, revealed 1. Dietary: Resident council resident stated she wanted a baked potato, and they didn't have one in the kitchen (06/10/2025 in the evening). Resident council resident says she eats in her room and the meals get to her late and she wants to know why. Resident council resident says she asked for a piece of bread on (06/11/2025) at the evening meal and didn't get it . Record review of [The Facility] Resident Council Responses, dated 06/12/2025, revealed talked to kitchen and they had some (potatoes) coming on the next truck order the next day. Resident's hall is sometimes last to serve, new cook starting 06/23/2025 and new staff. The staff will be informed of times and will improve on getting to halls on time. Resident was told they had ran out of bread and it was coming on next truck order the next day . Record review of Love, Satisfaction, and Well-being form, dated 06/15/2025, revealed Event: Meal (Food Preference); Resident #2 complained that kitchen staff prepared food like it was 'prison food.' Complained that he did not receive condiments last night with hamburger. Another time he did not receive toppings with baked potato. Additional Follow-up Action, If Applicable Dietary Manager also visited with him about food preferences and to ensure that all condiments, etc . were on the meal tray. Record review of the facility's policy Preparing the Resident for a Meal, revised September 2010, revealed The purpose of this procedure is to prepare the resident and the environment in order to help make mealtime pleasant for the resident.

Based on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in locked compartments for one of eight medication carts (Nurse med cart #1) in that: The facility's nurse medication cart (Nurse med cart #1) was left unlocked, unattended, and out of LVN B's view outside room [ROOM NUMBER] on 02/04/25. This failure placed residents at risk of their medications being stolen or misused and health complications related to accidental ingestion of drugs and/or biologicals, including hospitalization and death, Findings included: During an observation in 300 hallways on 02/04/25 from 2:39 PM to 2:50 PM, the Nurse medication cart (Med cart #1) was unlocked, with drawers able to be opened. There were insulins (medications that can lower blood sugars), prescription medications pills, over the counter medications, and breathing treatments inhalers containing albuterol, (a medication that causes nervousness, shakiness, throat/nasal irritation, muscle aches, and trembling). Three staff members were observed walking past the unlocked and unattended Nurse Med cart #1 at 2:40 PM, 2:48 PM and at 2:50 PM. During an interview on 02/04/25 at 2:55 PM, LVN B stated she forgot to lock the nurse med cart#1 when it was unattended and out of her view. She stated, I forgot to lock it. LVN B stated the medication carts should never be left unlocked when unattended because anyone could walk up and get into the medications on the cart. LVN B stated the expectation was the medication cart was always locked when no one was using it. In an interview with ADON on 02/05/25 at 08:55 AM, ADON stated LVN B was an agency nurse, and she had been in serviced before working on the floor about many things including medication safety and storage of medication. The ADON stated LVN B verbalized understanding. The ADON stated the medication carts should always be locked to decrease the risk of residents, especially residents with dementia, getting into the cart and accessing medications or treatment items. During an interview on 02/05/25 at 09:12AM, the DON stated the expectation was all the medication carts were locked when not in use and unattended to decrease the risk of residents and unauthorized persons getting into the cart and accessing medications. Record review of the facility's policy titled Storage of Medications, with a revision date of April 2019, reflected, in part, The facility stores all drugs and biologicals in a safe, secure, and orderly manner ., Unlocked medication carts are not left unattended.

51047 Based on observation, interview and record review, the facility failed to maintain an infection prevention and control measure designed to provide a safe, sanitary environment to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #3 and Resident #81) reviewed for infection control in that: 1.CNA A failed to put on Personal Protective Equipment (PPE) while providing perineal care to Resident #3, who is on EBP. 2. LVN B failed to put on PPE while administering medications and tube feeding via G-tube for Resident #81 who was on EBP for G-tube (a g-tube is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have difficulty swallowing). These deficient practices could place residents and nursing staff at risk of transmission of communicable diseases and infections. Findings include: 1.Review of Resident #3 face sheet, dated 2/4/2025, revealed that Resident #3 is a [AGE] year-old male admitted on [DATE] with diagnosis of Alzheimer's disease, hemiplegia (paralysis that affects one side of body) following a stroke, protein-calorie malnutrition. Review of Resident #3 care plan, dated 12/3/2024, revealed that Resident #3 is at increased risk of multidrug-resistant organism (MDRO) due to having a foley catheter. His care plan stated that EBP care should be maintained for Resident #3 until his foley catheter is no longer needed. Review of Resident #3 order, dated 4/2/2024, revealed that Resident #3 is on EBP for urinary catheter and gown & gloves should be worn during high- contact care. Observation on 2/4/2025 at 09:49 AM, CNA A answered Resident #3 call light. CNA A performed hand hygiene before entering Resident #3 room. Resident #3 door had EBP sign posted. Resident #3 asked CNA to change his soiled brief because he had a bowel movement. CNA A did not put on gown and proceeded to provide perineal care for Resident #3. CNA used gloves, and hand hygiene was performed by CNA A while she provided care for Resident #3. Resident #3 has a foley catheter. In an interview on 2/4/2025 at 10:00 AM, CNA stated that she has worked at the facility for 4 years. She admitted that after she provided care for Resident #3, she realized that he is on EBP, and she forgot to put on a gown. She stated she understands during high-contact care; she should put on gown and gloves. She stated the risk of not donning PPE would be the spread of infection. She has had in-service on EBP last month provided by the DON. In an interview on 02/06/25 at 09:31 AM with DON, she stated CNA A came to her on 2/4/2025 after she provided care for Resident #3 without putting on PPE. DON provided 1:1 in-service to CNA A on the same day. The DON stated that staff should put on PPE when providing care for wounds, indwelling devices, port access, IV line, any high-contact care. She also stated that staff is encouraged to ask any of the facility nurses or the ADON and DON if they are unsure about putting on PPE. She stated that the risk of staff not following the precaution is the spread of infection. She provides in-service on infection control quarterly as required, and any time an issue or concern arises. She stated that everyone was in charge of reminding each other to practice infection control. The ADON and DON are responsible for making sure staff follow infection control protocol. 2. Review of Resident #81's face sheet dated 02/06/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included sequelae of cerebral infarction (this is a condition of depression and anxiety after a stroke), difficulty speaking after stroke, difficulty swallowing, and gastrostomy malfunction (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing). Review of Resident #81's admission MDS assessment dated [DATE], revealed the resident's BIMS score was 0, indicating she was unable to be assessed. The MDS Assessment reflected Resident #81 was usually unable to be understood by others. Further review revealed Resident #81 was dependent on staff for all ADLs and required a feeding tube to obtain 51 % or more nutrition. MDS reflected Resident #81 was dependent on staff for all upper and lower bed mobility including turning and repositioning in bed. Review of Resident #81's care plan initiated 10/02/24, revealed Resident #81 was on EBP related to patients that were indicated for the following residents who are: Known to be colonized or infected with a multidrug-resistant organism. (MDRO) when Contact Precautions do not otherwise apply at increased risk of MDRO acquisition - G-Tube. The goal was EBP care should be maintained for Resident #81's entire stay or until wounds have healed or indwelling medical device is no longer needed. The interventions included making sure PPE was available immediately outside the room, provide patient standard precautions using gowns and gloves during dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use and wound care. Review of Resident #81's February physician orders on 02/04/25 reflected: -Gabapentin Oral Capsule (Gabapentin) Give 100 mg via G-Tube three times a day related to unspecified sequelae of cerebral infarction. - Nursing intervention: implement and maintain enhanced barrier precautions when performing high contact care activities. Resident is on EBP for G-tube. Every shift for EBP. Observation on 02/04/25 at 2:35 PM revealed LVN B did not put on her gown for EBP while administering medications to Resident #81 via G-tube. In an interview with LVN B on 02/04/25 at 2:55 PM, she stated she was nervous being watched, that was why she forgot to wear the gown for enhance barrier precaution. She stated the expectation was to follow infection control precautions of hand hygiene and [NAME] PPE for residents on EBP. She stated the risk to the resident was contamination of the medication she took with her bare hands, and she also risked exposing the resident to infection for not wearing PPE for EBP. In an interview with ADON on 02/05/25 at 08:55 AM, ADON stated LVN B was an agency nurse, and she had been in- serviced before working on the floor about many things including G-tube and infection control. She stated LVN B had verbalized understanding and the ADON had gone over G-tube Medication Administration-Skills assessment before she worked with the residents. The ADON stated the expectation was that all staff including agency staff follow the infection control policy. In an interview with the DON on 02/05/25 at 09:12 AM, it was revealed that LVN B's competencies were done by the agency, and it was the agency's responsibility to verify them before employment. She stated LVN B froze up because she was nervous. DON stated that the ADON went over EBP, she (LVN B) was educated before she did any procedure until she confirmed she was ready to perform them. DON stated there was nothing they felt LVN B could not have done competent wise as a nurse even when she had worked in the past. DON stated its expectation was to follow EBP protocol and to follow all infection control. DON stated LVN B did a lot of things wrong and she was pulled off the floor and sent home. Record review of facility's Infection Prevention and Control Program, dated August 2016, revealed that those with potential direct exposure to blood or body fluids are trained in and required to use appropriate precautions and personal protective equipment. Record review of facility's Enhanced Barrier Precaution policy, dated March 2024, revealed that one example of EBP resident include those with indwelling medical devices - include central lines, urinary catheters, feeding tubes, and tracheostomies/vents. EBP policy also stated that EBP are indicated during dressing, bathing/showering in a shared common shower room, transferring, providing hygiene, changing briefs or assisting with toileting . The policy also stated that gowns and gloves are used during high-contact sessions.

Based on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights for 2 of 4 residents (Resident #4 and Resident #19) reviewed for care plans in that: The facility failed to ensure that Resident #4 and Resident #19 use of bed rails/grab bars/mobility bars/transfer bars were documented in their care plans. The facility's failure placed residents requiring care at risk of not having their individual needs met, not receiving necessary care and services, and a failure to ensure continuity of care. Findings included: Record Review of Resident #4's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #4 had relevant diagnoses of Parkinson's Disease (progressive neurodegenerative disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled movements), with fluctuations; Alzheimer's Disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior); unspecified dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cerebral infarction (condition where blood flow to the brain is interrupted, causing brain tissue to die; also known as an ischemic stroke); depression; anxiety disorder; insomnia; dizziness and giddiness; other reduced mobility; Type 2 Diabetes Mellitus with diabetic nephropathy (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels); unsteadiness on feet. Record Review of Resident #4's Quarterly MDS, dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Resident #4's functional limitations in range of motion were listed as impairment for lower extremities on both sides of the body. Resident #4 was noted to use a manual wheelchair for mobility. Resident #4 was noted to need substantial/maximal assistance for self-care categories of oral hygiene, toileting, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #4 was noted to need substantial/maximal assistance in the mobility categories of roll left and right and tub/shower transfer. Resident #4 was reflected to need partial/moderate assistance for sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer and toilet transfer. Record review of Resident #4's Care Plan, last updated on 2/05/2025, reflected focus areas of an ADL Self Care Performance Deficit with interventions of encourage the resident to use bell to call for assistance; Bed Mobility, Toilet Use, Transferring all requires Extensive assistance. Resident #4 had a focus area of potential for pressure ulcer development with interventions of educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, and Low air loss mattress to bed. There was no mention of bed rails/grab bars as a focus area or intervention in the care plan. Observation of Resident #4's room and bed on 2/04/2025 at 11:57 AM revealed grab/mobility bar on the left side of the bed raised, the right side of the bed against the wall; resident was not in the room. Observation on 2/05/2025 at 8:08 AM of Resident #4's room area and bed revealed the resident had been moved to another room; left side grab/mobility bar remained raised and right side of bed against wall; resident was sleeping soundly at time of observation and did not wake to his name being spoken. Resident not able to be interviewed. Record review of Resident #19's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #19 had relevant diagnoses of Hemiplegia And Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side (paralysis or severe weakness on one side of the body caused by a stroke), Chronic Obstructive Pulmonary Disease With (Acute) Exacerbation (chronic lung disease that makes it difficult to breathe caused by damage that narrows airways making it harder to move air in and out of the lungs), Acute And Chronic Respiratory Failure With Hypoxia (when lungs are unable to exchange gases properly with blood), Obstructive (condition where urine flow is blocked within the urinary tract, causing urine to back up) And Reflux (where urine flows backwards from the bladder into the ureters typically due to a faulty valve mechanism) Uropathy (conditions that can potentially damage the kidneys), Need For Assistance With Personal Care, Cognitive Communication Deficit, Unspecified Lack Of Coordination, Other Reduced Mobility, Occlusion And Stenosis Of Unspecified Carotid Artery (narrowing or complete blockage of blood flow in one of the carotid arteries in the neck), Acute Kidney Failure, Unsteadiness On Feet, History Of Falling, Weakness, Right Hand Contracture, Muscle Weakness (Generalized), Other Lack Of Coordination. Record review of Resident #19's Quarterly MDS, dated [DATE], reflected a BIMS score of 12, which indicated a moderate cognitive impairment. The Quarterly MDS also showed that Resident #19 had impairment to bilateral lower body and too the right side of the upper body. Resident #19 was noted to have utilized a motorized wheelchair for mobility; required substantial/maximal assistance for oral hygiene, toileting hygiene, showering/bathing, upper and lower body dressing, putting on/taking off footwear, personal hygiene, sit to lying, rolling right and left, tub/shower/toiler transfers, lying to sitting on side of bed, sit to stand, and chair/bed-to-chair transfers. Observation on 2/04/2025 at 3:04 PM of Resident #19 room area and bed revealed that the bed had a floor and ceiling tension mounted grab/transfer bar next to the left-hand side of the bed with the right-hand side of the bed against the wall. The resident was not in the room at the time. Observation on 2/05/2025 at 8:10 AM of Resident #19's room area and bed revealed the grab/transfer bar in the same location. Interview on 2/05/2024 at 1:25 PM with Resident #19 stated that he used the grab/transfer bar during personal care by aides, to help roll and for repositioning while in bed. Record review of Resident #19's Care Plan, last updated on 12/07/2024, reflected that Resident had ADL self-care performance deficit r/t hemiplegia and required interventions of BED MOBILITY: EXTENSIVE assistance X2 Staff, EATING: SUPERVISION and SET-UP assistance, TOILET USE: EXTENSIVE assistance X2 Staff, TRANSFERRING: EXTENSIVE assistance X2 Staff. Resident #19 had limited physical mobility r/t Right Hemiplegia with Right hand contracture with splint to knees and required interventions of NON-WEIGHT BEARING, ACTIVITIES: Invite to activity programs that encourage physical activity, physical mobility, such as exercise group, walking activities to promote mobility, Monitor/document/report PRN any s/sx of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury, Provide gentle range of motion as tolerated with daily care The Care Plan had no mention of grab/transfer bar as an intervention or focus for Resident #19. Interview on 2/06/2025 at 12:10 PM with CNA D revealed that if a resident had grab/transfer bars raised on or installed next to their bed, a conversation would happen with the resident about what they used the bars for, then they would have made sure the resident had approval for the bars on the Kardex, an electronic nursing worksheet that shows resident information such as medications, care schedules, and follow-ups based on a resident's care plan, and would have also checked with the charge nurse why the grab/transfer bars were on the resident bed. CNA D stated that the nurses are responsible for updating the care plan that shows in the Kardex they review for resident care information. Interview on 2/06/2025 at 12:11 PM with the DON revealed that usually either the DON, an ADON, a MDS nurse, or the admission nurse would have completed the assessments at admission including the bed rail/grab bar assessment for each new or returning resident and if the resident were assessed to be safe using grab/transfer bars then there would be a need to obtain signed consent or notify the resident's responsible party for verbal consent. The use of the grab/transfer bars would be documented in the resident's care plan. If a staff member sees a resident with a bed that had grab/transfer bars on it that was not care planned, the care plan should be updated by either the MDS nurse or done by the staff member who had possibly completed the assessment; the care plan may also be updated by an ADON or DON based on who is available. The DON also stated that if a resident were assessed to not be safe using grab/transfer bars and has the grab/transfer bars on the bed then nursing should have picked up on that during the multiple daily rounds. The DON stated that if a resident were not assessed as safe, there were no consent, and the grab/transfer bar use was not in care plan there could be a risk to the resident that would be considered small, a minor risk to injury, but the grab/transfer bars should not be on the bed as the resident assessment said they were not safe. When asked about the lack of care planning of the grab/transfer bar for Resident #4 and Resident #19, The DON stated she would have to look into the records of the residents to see what happened and would then correct any missing information for the residents. Interview on 2/06/2025 at 12:53 PM with LVN F revealed that resident care plans were updated quarterly and annually by the MDS nurses. The MDS nurses were to make sure all resident triggers were documented along with all diagnoses, high risk medications, and equipment/items used such as grab/transfer bars. LVN F stated that for grab/transfer bars the process included the safety assessment, obtaining a consent signature or documenting verbal consent from a responsible party, and documenting in the care plan why the grab/transfer bars were needed. LVN F stated if a staff member noticed there were grab/transfer bars on a resident bed, that staff member should make sure all documentation was up to date and if not to bring it up in the weekly IDT meeting. LVN F stated that if a staff member asked a nurse why a resident had grad/transfer bars on their bed the nurse would go to the resident's chart and look for the care plan item to provide the information. Record Review of the facility's Care Plans, Comprehensive Person-Centered, 2001 MED-PASS, Inc. (Revised January 2025), policy statement was 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. The policy interpretation and implementation stated: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record Review of the facility's Proper Use of Side Rails policy states the purpose is To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Relevant sections include: Definition: Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) General Guidelines: 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms and/or to assist with mobility and transfer of residents. 3. Upon admission, readmission, with routine quarterly or significant change MDS and PRN, therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to side of bed and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails . 4. Consent for use of side rail will be obtained from the resident or legal representative, after presenting potential benefits and risks. 5. The resident's care plan will reflect the use of side rails and updated as necessary . 7. Least Restrictive devices will be reviewed and recommendations if indicated will be attempted prior to use of siderails 8. Once least restrictive alternatives to bed rails have been determined to not meet the resident's needs, if a bed rail is necessary, the resident assessment should be considered in determining proper side rail placement.

Based on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 (Resident #81) of 4 residents reviewed for enteral nutrition in that: 1.LVN B failed to obtain physician orders for water to flush Resident #81's G-tube before medication administration and after medication administration via the G-tube. 2. LVN B failed to hold tube feeding for 30 minutes after medication administration for Resident #81 per facility policy. 3. LVN B pushed all medication and water with a syringe and plunger instead of using gravity gentle flow (this is a method used by attaching a feeding syringe without the plunger to allow water, medications and food to enter the stomach vis G-tube gently without force of pushing) to administer medications and water via G-tube for Resident #81. These deficiency practices could affect residents who receive tube feedings by not receiving the appropriate nutrition/ hydration and causing complications. The findings included: Review of Resident #81's face sheet dated 02/06/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included sequelae of cerebral infarction (this is a condition of depression and anxiety after a stroke), difficulty speaking after stroke, difficulty swallowing, and gastrostomy malfunction. Review of Resident #81's admission MDS assessment dated [DATE], revealed the resident's BIMS score was 0, indicating she was unable to be assessed. The MDS Assessment reflected Resident #81 was usually unable to be understood by others. Further review revealed Resident #81 was dependent on staff for all ADLs and required a feeding tube to obtain 51 % or more nutrition. MDS reflected Resident #81 was dependent on staff for all upper and lower bed mobility including turning and repositioning in bed. Review of Resident #81's Care plan initiated 12/04/24 revealed Resident #81 had required a feeding tube due to dysphagia (difficulty swallowing). The goal was for Resident #81 to remain free of side effects or complications related to tube feeding through the review date. The interventions included; The resident needs the HOB elevated 30-45 degrees during and thirty minutes after tube feed, Check for tube placement and gastric contents/residual volume per facility protocol and record, Observe/document/report as needed any s/sx of: Aspiration- fever, SOB , Tube dislodged, Infection at tube site, Self-extubating (pulling out g-tube), Tube dysfunction or malfunction, Abnormal breath/lung sounds, Abnormal lab values, Abdominal pain, distension, tenderness, Constipation or fecal impaction, Diarrhea, Nausea/vomiting, Dehydration, Provide local care to G-Tube site as ordered and monitor for s/sx of infection, Registered Dietician to evaluate quarterly and PRN. Monitor caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed, Speech therapist evaluation and treatment as ordered. Review of Resident #81's order summary for February 2025 reflected the following: - Gabapentin Oral Capsule (Gabapentin) Give 100 mg via G-Tube three times a day related to unspecified sequelae of cerebral infarction - Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 1 tablet via G-Tube two times a day for Constipation - Hydrocodone-Acetaminophen Tablet 7.5-325 MG Give 1 tablet by mouth every 6 hours for Pain Crush and administer via g-tube. - Enteral Feed Order two times a day Enteral: Enteral Nutrition [brand name] 1.5 at 65 ml per hour for (20) hours via pump. Start infusion at 2pm and continue until 10 am for a total of 20 hours. Set [brand name] pump water flushes at 150 ml every 4 hours. - Enteral Feed Order every shift Enteral: Crush or open capsules and dilute each medication with 5 to 10 ml of water if indicated. Observation on 02/04/25 at 2:35 PM revealed LVN B picked a feeding syringe with plunger attached and drew 30 cc of water into the feeding syringe attached it to Resident #81's G-tube and she pushed the 30 cc of water into the G-tube to flush Resident #81's G-tube before medication administered. She then unattached the feeding syringe and drew up one of the medications into the feeding syringe and re attached it to Resident #81's G-tube and pushed the medication. She removed the feeding syringe from the G-tube and drew up 10 cc of water into the feeding syringe and reattached it back to Resident # 81's G-tube and pushed the 10 cc of water into the G-tube. LVN B continued to attach and reattach and push all three medications and the 10 cc of water in between the medication and another 30 cc of water after medication administration via the G-tube of Resident #81. LVN B did not use the gravity gentle flow to administer medications and water via G-tube for Resident #81. LVN B attached the feeding right after medication administration. LVN B did not hold tube feeding for 30 minutes after medication administration. During an interview on 02/04/25 at 2:55 PM, LVN B stated she was a travel nurse and that she had been trained to use the syringe and plunger attached to help push the medication and water inside the G-tube. She stated this is how she had always done it. LVN B stated the ADON had given her a G-tube facility check off list this afternoon prior to her administering Resident #81's afternoon medications and restarting the feeding. LVN B stated she thought she saw the orders for water flush of 30 cc before medication and 30 cc after medication but when she was asked to show surveyor the order she stated I only see the 5-10cc. LVN B stated she would not be coming back to the facility, and she would call in the following day because she did not feel well prepared to have been watched. LVN B stated she was a travel nurse and only came to the facility occasionally, she had not been given any G-tube in-services. In an interview with ADON on 02/05/25 at 08:55 AM, ADON stated LVN B was an agency nurse, and she had been in serviced before working on the floor about many things including G-tube and infection control. She stated LVN B had verbalized understanding and the ADON had gone over G-tube Medication Administration-Skills assessment before she worked with the residents. ADON stated LVN B should not have used the plunger to push medication and water into the G-tube and should have let it free flow by gravity. ADON stated I was taught Never to push as it can damage the bulb of the G-tube. The ADON stated the expectations for all nurses, was that if there were no orders to do something to reach out to the NP and get orders. The ADON stated she may have been nervous and forgot because she was being watched. The ADON stated the expectation was that all staff including agency staff follow the G-tube medication administration and infection control policy. In an interview with the NP on 02/05/25 at 08:39 AM she stated with the G-tube you mainly push air when checking for placement by pushing 10 cc of air and when checking for residual and returning the residual. She stated you could push a small amount of water as needed when there was a clog as G-tubes tend to become clogged easily. She stated all G-tube should have water flush orders and she would look into the resident's order to make sure it was ordered. In an interview with the DON on 02/05/25 at 09:12 AM, it was revealed that LVN B's competencies were done by the agency she worked for, and it was the agency's responsibility to verify them before employment. The DON stated, it is not fair for you [surveyor] to write deficiency practice of G-tube when our own nurses do a great job, she [LVN B] is agency. The DON stated that the ADON went over EBP, G-tube, and medication safety. She was agency, she stated LVN B froze up because she was nervous. The DON stated ADON went over EBP, she (LVN B) was educated before she did any procedure, and she said that she was ready. The DON stated there was nothing LVN B couldn't do skill wise as a nurse. The DON stated the expectation was to follow EBP protocol and to follow all infection control. The DON stated LVN B did a lot of things wrong and she was pulled off the floor and sent home. Record review order summary for Resident #81 on 02/05/25 at 12:37 PM reflected Enteral Feed Order every shift Enteral: Flush feeding tube with 30 to 60 ml of water before and after each medication administration ordered by NP. Active 02/05/2025. Record review of facility policy titled Enteral nutrition revised 2/13/2007 reflected, We will provide nutritionally complete enteral or parenteral feedings as ordered by the physician for the nourishment of residents who are unable to eat by mouth. Review of facility policy titled Administering Medication through an Enteral Tube revision date July 5, 2019, reflected .read in part . Verify that there is a physician's medication order for this procedure, restarted at least 30 minutes after medication administration as indicated by the Physician 9.Consult the physician if there are any questions regarding compatibility, or if going this time period without feedings may compromise the resident 13.When correct tube placement and acceptable GRV have been verified, flush tubing with 15-30 mL water (or prescribed amount) Reattach syringe (without plunger) to the end of the tubing. 18. Administer medication by gravity flow. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver medication slowly. c. Clamp tubing (or begin flush) before the tubing drains completely. 19. If administering more than one medication, flush with 15 mL (or prescribed amount) water between medications. 20. When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of tap water (or prescribed amount .

Based on observations, interviews, and record review the facility failed to assess the risks and benefits of bed rails and grab bars with the resident or resident representative or obtain informed consent prior to installation for one (Resident #4) of four resident rooms observed and reviewed for bed rails/enabler bars. The facility failed to have evidence of informed consent and assessment of the resident for risk of entrapment for bed rails or grab bars for Resident #4. This failure could place residents who used bed rails/grab bars at risk of the resident not being assessed for bed rails or grab bars, resident/responsible party not being aware of the risks, and informed consent not being obtained from the resident or responsible party. Findings included: Record Review of Resident #4's Face Sheet reflected a [AGE] year-old male who initially admitted to the facility on [DATE]. Resident #4 had relevant diagnoses of Parkinson's Disease (progressive neurodegenerative disorder that affects movement, balance, and coordination) with dyskinesia (involuntary, uncontrolled movements), with fluctuations; Alzheimer's Disease (progressive neurodegenerative disorder that affects memory, thinking, and behavior); unspecified dementia (condition in which a person loses the ability to think, remember, learn, make decisions, and solve problems), unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; cerebral infarction (condition where blood flow to the brain is interrupted, causing brain tissue to die; also known as an ischemic stroke); depression; anxiety disorder; insomnia; dizziness and giddiness; other reduced mobility; Type 2 Diabetes Mellitus with diabetic nephropathy (disease that occurs when the body does not respond properly to insulin leading to high blood sugar levels); unsteadiness on feet. Record Review of Resident #4's Quarterly MDS, dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Resident #4's functional limitations in range of motion were listed as impairment for lower extremities on both sides of the body. Resident #4 was noted to use a manual wheelchair for mobility. Resident #4 was noted to need substantial/maximal assistance for self-care categories of oral hygiene, toileting, shower/bathing, upper and lower body dressing, putting on/taking off footwear, and personal hygiene. Resident #4 was noted to need substantial/maximal assistance in the mobility categories of roll left and right and tub/shower transfer. Resident #4 was reflected to need partial/moderate assistance for sit to lying, lying to sitting on side of the bed, sit to stand, chair/bed-to-chair transfer and toilet transfer. Record review of Resident #4's Care Plan, last updated on 2/05/2025, reflected focus areas of an ADL Self Care Performance Deficit with interventions of encourage the resident to use bell to call for assistance; Bed Mobility, Toilet Use, Transferring all requires Extensive assistance. Resident #4 had a focus area of potential for pressure ulcer development with interventions of educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning, and Low air loss mattress to bed. Resident #4 had a focus area of Skin Tear/potential for skin tear with interventions of identify potential causative factors and eliminate/resolve when possible, and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Review of Medical Record of Resident #4 revealed no signed bed rail/grab bar consent form signed by the resident or resident's responsible party or noted to have verbal permission for the enabler bars. Observation of Resident #4's room and bed on 2/04/2025 at 11:57 AM revealed grab/mobility bar on the left side of the bed raised, the right side of the bed against the wall; resident was not in the room. Observation on 2/05/2025 at 8:08 AM of Resident #4's room area and bed revealed Resident #4 had been moved to another room and the left side grab/mobility bar remained raised and right side of bed against wall; resident was sleeping soundly at time of observation and did not wake to his name being spoken. Resident not able to be interviewed. Interview on 2/06/2025 at 12:10 PM with CNA D revealed that if a resident had grab/transfer bars raised on or installed next to their bed, a conversation would happen with the resident about what they used the bars for, then they would have made sure the resident had approval for the bars on the Kardex, an electronic nursing worksheet that shows resident information such as medications, care schedules, and follow-ups based on a resident's care plan, and would have also checked with the charge nurse why the grab/transfer bars were on the resident bed. Interview on 2/06/2025 at 12:20 PM with the LVN E revealed that it was important to check a resident's chart for orders for bed rails/grab/transfer bars because if there was no order then the resident should not have them on or next to their bed. LVN E stated grab/transfer bars were only used for resident positioning, bed rails were not used as they would have been considered a restraint. LVN E stated that if a resident were assessed not appropriate for grab/transfer bars or did not have consent and the resident had a bed with grab bars on it, the grab bars should have been reported in the TELS system for maintenance to remove them as well as calling maintenance to request the removal. LVN E stated as part of the process conferring with other staff on why the grab/transfer bars were on the bed would also be conducted to see if the resident needed new evaluations and to obtain consent. Interview on 2/06/2025 at 12:41 PM with the DON revealed that usually either the DON, an ADON, a MDS nurse, or the admission nurse would have completed the assessments at admission including the bed rail/grab bar assessment and obtaining consent for each new or returning resident and if the resident were assessed to be safe using grab/transfer bars then there would be a need to obtain signed consent or notify the resident's responsible party for verbal consent. The use of the grab/transfer bars would be documented in the resident's care plan. If a staff member sees a resident with a bed that had grab/transfer bars on it that was not care planned, the care plan should be updated by either the MDS nurse or done by the staff member who had possibly completed the assessment; the care plan may also be updated by an ADON or DON based on who is available after verifying the consent was obtained. The DON also stated that if a resident were assessed to not be safe using grab/transfer bars and has the grab/transfer bars on the bed then nursing should have picked up on that during the multiple daily rounds. The DON stated that if a resident were not assessed as safe, there were no consent, and the grab/transfer bar use was not in care plan there could be a risk to the resident that would be considered small, a minor risk to injury, but the grab/transfer bars should not be on the bed as the resident assessment said they were not safe. When asked about Resident #4 not having informed consent, the DON stated she would have to look into that and would address any missing items related to bed tails/grab bars immediately. Interview on 2/06/2025 at 12:53 PM with LVN F revealed that resident care plans were updated quarterly and annually by the MDS nurses. The MDS nurses were to make sure all resident triggers were documented along with all diagnoses, high risk medications, and equipment/items used such as grab/transfer bars. LVN F stated that for grab/transfer bars the process included the safety assessment, obtaining a consent signature or documenting verbal consent from a responsible party, and documenting in the care plan why the grab/transfer bars were needed. LVN F stated if a staff member noticed there were grab/transfer bars on a resident bed, that staff member should make sure all documentation was up to date and if not to bring it up in the weekly IDT meeting. LVN F stated that if a staff member asked a nurse why a resident had grad/transfer bars on their bed the nurse would go to the resident's chart and look for the care plan item to provide the information. Record Review of the facility's Care Plans, Comprehensive Person-Centered, 2001 MED-PASS, Inc. (Revised January 2025), policy statement was 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. The policy interpretation and implementation stated: 1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . 3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; . 9. Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. 10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Record Review of the facility's Proper Use of Side Rails policy states the purpose is To ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. Relevant sections include: Definition: Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: The definition of restraints is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint.) General Guidelines: 1. Side rails are considered a restraint when they are used to limit the resident's freedom of movement (prevent the resident from leaving his/her bed). (Note: the side rails may have the effect of restraining one individual but not another, depending on the individual resident's condition and circumstances. 2. Side rails are only permissible if they are used to treat a resident's medical symptoms and/or to assist with mobility and transfer of residents. 3. Upon admission, readmission, with routine quarterly or significant change MDS and PRN, therapy/designee will complete the Side Rail Utilization Assessment, or equivalent form to determine the resident's symptoms, risk of entrapment and rationales for using side rails prior to implementation. When used for mobility or transfer, the assessment will include a review of the resident's: a. Bed mobility; b. Ability to change positions, transfer to side of bed and from bed or chair, and to stand and toilet; c. Risk of entrapment from the use of side rails . 4. Consent for use of side rail will be obtained from the resident or legal representative, after presenting potential benefits and risks. 5. The resident's care plan will reflect the use of side rails and updated as necessary . 7. Least Restrictive devices will be reviewed and recommendations if indicated will be attempted prior to use of siderails 8. Once least restrictive alternatives to bed rails have been determined to not meet the resident's needs, if a bed rail is necessary, the resident assessment should be considered in determining proper side rail placement.

Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 (Resident #1) of 4 residents reviewed for quality of care. The facility failed to ensure Resident #1's oxygen tubing was dated. This failure placed the residents at risk for infections and respiratory related complications. The findings were: Record Review of Resident #1 admission record reflected; [AGE] year-old-female with an initial admitted [DATE] and a preliminary diagnosis of: CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED Record Review of Resident #1's MDS Optional State assessment dated [DATE] reflected; Resident #1 had a BIMS score of 07 (Severe cognitive impairment). Record Review of Resident #1's Care Plan reflected; Focus: The resident has oxygen therapy r/t Chronic Respiratory illness; Intervention: OXYGEN SETTINGS: O2 via (nasal prongs/mask) Record Review of Resident #1's Order Summary reflected active orders dated 05/10/2024 reflected Oxygen: May have oxygen at (2-4) LPM related to COPD every 24 hours as needed. Oxygen: May have oxygen at 2-4 LPM] Liters per via NASAL CANNULA; MAY REMOVE FOR ADLS; KEEP HOB ELEVATED FOR SOB WHILE LAYING FLAT every 6 hours for SOB Record Review of Resident #1's Care Plan reflected; Focus: The resident had oxygen therapy r/t Chronic Respiratory illness; Intervention: OXYGEN SETTINGS: O2 via (nasal prongs/mask) Record Review of Resident #1's MDS Optional State assessment dated [DATE] reflected; Resident #1 had a BIMS score of 07 (Severe cognitive impairment). Section I- Active Diagnoses- Pulmonary; Asthma, COPD, or Chronic Lung Disease (e.g. chronic bronchitis and restrictive lung diseases such as asbestosis). Section J- Health Conditions- Shortness of breath or trouble breathing when lying flat. Section O- Special Treatments, Procedures, and Programs; Oxygen therapy, performed while a resident of this facility. Record Review of Resident Priority Program check list , undated, reflected: Equipment: 24 Oxygen: If resident uses oxygen, was the bag dated and initialed no greater than one week . Portable oxygen full. Oxygen tubing not on floor, labeled and dated. Observation on 05/10/2024 at 11:48 AM revealed Resident # 1 was lying in her bed, on her back, with the head of her bed slightly raised. Resident #1 was awake wearing a nasal cannula tube that extended and connected to oxygen concentrator next to her bed. Observation revealed that the oxygen tube was not dated. Interview with ADON A on 05/10/2024 at 2:41 PM revealed she did observe that the oxygen tubing for Resident #1 was not dated. She stated that every Sunday, the night nurse had the task of changing and dating oxygen tubing, mask, and humidifier. She stated there was a room round sheet that was used to check and see if the task was completed. The risk of not dating the tubing was infection control. The risk of bacteria in the tubing. Interview with ADON B on 05/10/2024 at 2:58 PM revealed the Sunday night nurse had the task of making sure that the oxygen tubing was dated. This task was completed weekly and checked off in the electronic medical record. She stated that there was a room round sheet completed by the ADON to make sure the task was completed. The risk of not labeling and dating oxygen tubing for the resident was the resident could be exposed to bacteria and cause pneumonia. Review of policy Oxygen Administration dated October, 2010 reflected; Documentation, after completing the oxygen setup or adjustment, the following information should be recorded in the resident's medical record: 1. The date and time that the procedure was performed.

Based on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is an accident involving the resident which results in injury and has the potential for requiring physician intervention for one (Resident #1) of eight residents reviewed for notification. LVN A failed to notify Resident #1 physician after resident fell in her room on 04/17/24. LVN A failed to notify Resident #1's responsible party after Resident# 1had a fall in her room on 04/17/24. These failures could place residents at risk for delayed physician intervention and risk of families not receiving notification of change in condition of residents. Findings included: Record review of Resident #1 's admission record dated 04/17/24, revealed an [AGE] year-old female that was admitted to the facility on [DATE]. Her diagnoses included rheumatoid arthritis (a condition in which the body attacks its own tissues typically in joints especially hands and feet), atrial fibrillation (irregular heartbeat), pacemaker (a small device used to treat irregular heartbeat), unsteady on her feet, urinary tract infection, rheumatic fever without heart involvement (, contusion of left hip (skin and deep tissue bruising), and idiopathic peripheral automatic neuropathy (nerve damage). Record review of Resident #1's quartery MDS assessment dated [DATE] reflected a BIMS score of 14, which indicated the resident was cognitively intact. Record review of Residents #1's care plan dated, 03/26/24, reflected .Focus: The resident was on anticoagulant therapy (resident takes blood thinner medication) related to (r/t) Atrial fibrillation. Date Initiated: 03/26/2024. Goal: The resident would be free from discomfort or adverse reactions related to anticoagulant use through the review date. Date Initiated: 03/26/2024. Interventions: Administer Xarelto ANTICOAGULANT medications as ordered by physician r/t atrial fibrillation. Monitor for side effects and effectiveness every shift. Daily skin inspection. CNA Report abnormalities to the nurse. Labs as ordered, report abnormal lab results to the MD. Monitor/document/report PRN adverse reactions of ANTICOAGULANT therapy: blood tinged or red blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, SOB, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs (v/s) Date Initiated: 03/26/2024 The care plan also reflected that resident had an actual fall related to poor balance on 04/08/24. The goal was that Resident #1 would resume usual activities without further incidents throw the review date 07/02/24. Interventions were: .To order blood work and place a call don't fall sign in restroom, Check range of motion daily, Continue interventions on the at-risk plan, For no apparent acute injury, determine and address causative factors of the fall, Monitor/document /report PRN x 72h to MD for signs and symptoms of Pain, bruises, Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation. Neuro-checks. Date Initiated: 04/08/2024 . Review of Residents #1's progress notes and MAR on 04/17/24 did not reflect notification to the physician of a fall or documentation of a fall that occurred 04/17/24. Interview with Resident #1 with her family in the room on 04/17/24 at 12:11 pm, revealed Resident #1 had a fall on 04/17/24. She said that she did not recall the exact time she fell , but it was around 7:00 AM. Resident #1 said that she did not call before going to bathroom by herself. She stated that she was transferring herself to the bed from the wheelchair when she lost her balance. She said she held onto the small bedside table, but it was not locked, and it slid from underneath her. She said she grabbed the privacy curtain as she fell to help break her fall to the ground. She said she landed on her bottom. The family stated that Resident #1 told her about the fall when they came to visit her around 10:00 AM. The family said that she was the responsible party and the first emergency contact, however, the facility did not notify her about Resident #1's fall. Resident #1 said her roommate pressed the call light and called for help. Resident #1 said that at the time she did not have much pain, so the nurse and CNA helped her into the bed. Resident #1 stated that the nurse did not assess her skin and did not do vitals. Resident #1 said she bruised easily due to blood thinners She said that the nurse gave her pain medication that was due at the time and applied a pain patch on her lower back . Interview with CNA B on 04/17/24 at 4:13 PM revealed that she found Resident #1 seated on the floor holding onto the privacy curtain. She said she immediately notified LVN A to come to the room. She said they asked the resident if she was hurt or in pain, but she denied new pain. She said after the nurse assessed Resident #1's pain, CNA B and LVN A then helped Resident #1 to the bed. CNA B said that she could not remember if LVN A checked her vitals or assessed Resident #1's skin because she had to leave the room after helping LVN A get Resident #1 back into the bed. Interview with LVN A on 04/17/24 at 2:01 PM, revealed Resident #1's fall happened between 06:45AM and 7:45 AM on 04/17/24. LVN A said Resident#1 was found on the floor holding the curtain. She said Resident #1 told her that after coming back from the bathroom she was transferring herself and she held onto the bedside table, but it slid from underneath her weight, and she grabbed the curtain as she sat to the ground. LVN A said her and CNA B helped Resident #1 up from the floor to the bed after a pain and range of motion assessment, which revealed no concerns as the resident did not express pain. LVN A said that she took Resident #1's vital signs but had not had time to input them in the MAR. LVN A said that she left a voicemail for Resident #1's family member and sent a text message to the physician. LVN A retrieved her text messages to show the surveyor, but she discovered that she forgot to notify the physician about Resident #1's fall. She said, I thought I included [Resident #1's] fall in the message together with another resident's physician notification. She said that she gave Resident #1 pain medication and applied a pain patch after the fall. LVN A said that the resident denied pain and stated that Resident #1 told her she was more embarrassed about the fall if anything. She did not see the risk because she did not consider what happened to have been a fall but that the resident let herself to the floor after beside table sled from under her hand. Interview with the ADON on 04/17/24 at 2:55 PM, revealed that she was not notified about Resident #1's fall prior to surveyor interviewing LVN A at 2PM. The ADON said that LVN A stated that she did not notify her of the incident because she did not consider Resident #1 had a fall because she lowered herself to the ground. The ADON said that the expectation was that LVN A should have notified her or upper management, the physician, and family about Resident #1 fall or any incident immediately. She said an incident report should have been created in the MAR to alert the IDT team. She said neuro checks should have been done because fall was unwitnessed, as the resident could have incurred a head injury. Staff should d not just go by what the resident said what happened alone. She said that she expected nursing staff to assess the patient, making sure nothing was wrong and check for bruising. She said the risk to the resident was an adverse effect and delay in treatment because if tomorrow she says she is hurt no one would know what happened. Interview with the Administrator on 04/17/24 at 5:49 PM, revealed he expected staff to follow facility policies and to treat an unwitnessed fall the same as the witnessed fall. He expected the nurse to perform neuro checks post fall and he expected the nurse to notify the ADON or DON, notify the doctor, and notify the family. Review of facility policy titles: Falls- Clinical Protocol, revision November 14, 2023, reflected in part the following: .The Nursing Staff with physician's assistance will also identify medical conditions affecting fall risk (for example, a recent stroke or medications that cause dizziness hypotension) and the risk for significant complications of falls (for example, increased fracture risk in someone with osteoporosis or increased risk of bleeding in someone taking an anticoagulant) . The Nursing Staff will evaluate, and document falls that occur while the individual is in the facility, for example, when and where they happen, any observations of the events, etc .For an individual who has fallen, the Nursing Staff with physician's assistance will begin to try to identify possible causes within the first 24 hours of the fall . After a fall, the physician should review the resident's gait, balance, and current medications that may be associated with dizziness or falling . Based on the preceding assessment, the Nursing Staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling .The Nursing Staff will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. The Charge Nurse will complete an assessment for seventy-two (72) hours post incident .The Nursing Staff will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling during the Standard of Care/High Risk Management Meetings .If interventions have been successful in fall prevention, the staff will continue with current approaches and will discuss periodically with the physician whether these measures are still needed; for example, if the problem that required the intervention has resolved by addressing the underlying cause . If the individual continues to fall, the Nursing Staff with the physician's assistance will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions .

Based on observation, interview, and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for one (Hall 400) of four halls. The facility failed to keep the environment free of flies. This failure could affect residents by placing them at risk for the potential spread of infection, food-borne illness, and decreased quality of life. Review of Resident #57's face sheet, dated 12/13/2023, reflected he was a [AGE] year-old male, admitted on [DATE] with diagnoses of unspecified dementia with behavioral disturbance, heart disease, and history of stroke. Review of Resident #57's MDS assessment, dated 12/05/23, reflected he was usually able to understand others and to be understood by them. He had a BIMS score of 14, indicating intact cognition. Resident #57 exhibited no behaviors or psychosis during the assessment period. He required partial to moderate assistance with most of his ADLs. Review of Resident #69's face sheet, dated 12/13/2023, reflected he was a [AGE] year-old male, admitted on [DATE], with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting left side (one-sided weakness following a stroke), epilepsy, and generalized anxiety disorder. Review of Resident #69's significant change MDS assessment, dated 09/24/23, reflected he was able to understand and be understood by others, and had a BIMS score of 14, indicating intact cognition. Resident #69 exhibited no behaviors or psychosis during the assessment period. He required extensive to total assistance for ADLs, except he was able to feed himself. An interview and observation on 12/12/23 at 10:13 AM of Resident #69 revealed him to be in his bed, watching TV. A fly was flying around his side of the room, and during the observation it landed on his blanket, the bedside table, a water cup, and the state surveyor. He said that they had flies sometimes but he was not too bothered by them. An interview and observation on 12/12/23 at 10:13 AM of Resident #57 revealed him to be in his room, lying on his bed. While talking with the state surveyor, he swatted a fly away from his face and body several times. It was observed landing on his shirt, bare arm, feet, and table. He said they usually had flies, but they were a lot worse when it was warm out. He said he killed a lot of flies every day in his room when it was warm, at least three or four a day, sometimes more. He said he told the staff when there were flies in the room, but they did not do anything about them, so he just killed them himself. An interview on 12/14/23 at 11:06 AM with Maintenance Director A revealed he was only part time, because he worked full time at a sister facility in a nearby town and came over to help out for about two hours a day. He said he had been doing that for about four weeks, because their former maintenance director was no longer employed there, and they were looking for someone else full time. Due to the limited time he had in the facility, he had to prioritize which issues he addressed. He was not aware if the facility had a fly program with their pest control company, and he had not looked at pest issues in the facility. He said when he got to the facility, he looked at the maintenance log, and he addressed the more urgent issues on it. An interview on 12/14/23 at 12:36 PM with the RDPO revealed, he was at the facility one to two days a week now. He said when he came in, he changed bulbs, fixed holes in the walls, repaired sinks and toilets, did the generator log, fire doors, and everything. He said he looked at the maintenance log, and he had a book that showed him what he needed to do each month. He said they did have a fly issue, they put bait around the dumpster, and got it under control around the middle of August of 2023. He said that people went in and out the door by the dining room all the time, and he felt like that was how the flies got in. He said that he walked the grounds, had done so that week, and he picked up cigarette butts people left, but did not see problems with flies or trash. He said he had not seen flies in the building and had not heard complaints from residents about flies in their rooms. He said because they had once been a problem, they put some fly lights in the dining room, one in the kitchen, and they changed the sticky boards in them out monthly. He said it would be the Maintenance Director's duty to review the pest control recommendations, and that had probably not been done since he was out with an injury. An interview on 12/15/23 at 3:51 PM with the Administrator revealed, he was not aware of current issues with flies in the resident rooms. He said the Maintenance Director would have had the responsibility for monitoring the grounds and addressing pest issues, but he had been out on prolonged workman's compensation leave, so they could not replace him, and it had been a struggle for the facility. He said recently the former Maintenance Director said he would not be coming back, so they started looking for another Maintenance Director. He said Maintenance Director A was coming to help him out, but he was there two to three hours a day, and RDPO was coming in and helping them some too. He said they had done things to address houseflies, like the fly trap devices they installed, and he felt the best thing was that they kept things clean to help keep them out. He said the flies were a contamination risk. Review of a pest control invoice for a visit on 12/04/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 12/04/23. Review of a pest control invoice for a visit on 11/15/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 11/15/23. Review of a pest control invoice for a visit on 11/01/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 11/01/23. Review of a pest control invoice for a visit on 10/16/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 10/16/23. Review of a pest control invoice for a visit on 10/02/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 10/02/23. Review of a pest control invoice for a visit on 09/18/23 reflected treatment of the building for flies. It reflected Open Conditions: Exterior- Dumpster Area: Condition: Dumpster/ Trash can uncovered; Action: Keep dumpster lids and doors closed to reduce fly population The note was marked with a severity of high and responsibility customer and was created on 03/06/23, and last inspected on 09/18/23. Review of the undated facility Pest Control policy reflected Pest Control: Policy Statement: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept as free as possible of insects and rodents. 2. Pest control services are provided by [pest company name]. ( .) 4. Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to date and label food items in the walk-in refrigerator of the facility's kitchen. These failures affected residents by placing them at risk for contamination and food-borne illness. Findings included: An observation of the walk-in refrigerator on [DATE] at 8:50 AM revealed: - 1 basket of sandwiches that appeared to contain peanut butter and jelly undated and unlabeled - 1 small Tupperware container with 4 cut up pieces of tomato undated and unlabeled - 1 piece of meat that appeared to be ham in a Ziploc bag undated and unlabeled - 2 Large Ziploc bags containing a sandwich, a pack of crackers, cookies and a water bottle. Both bags undated and unlabeled - 2 Large zip loc bags with what appeared to be fried chicken undated and unlabeled - 1 Large Ziploc bag with several items individually wrapped with aluminum foil undated and unlabeled - 1 cube shaped container with an unknown white substance (appears it could be potato salad or chicken pureed), undated and unlabeled - 2 large Pitchers with a red liquid, undated and unlabeled An observation upon exit of the walk-in refrigerator revealed a sign on the door that stated, STOP!! Did you date and label. In an interview on [DATE] at 9:06 AM Cook E stated the staff knew that everything should be dated and labeled. She stated the sandwiches were made that morning for the morning snack. Cook E stated it was important to date and label food items to ensure the items did not expire and to prevent resident sickness. In an interview on [DATE] at 2:30 PM the Dietary Manager (DM) stated the expectation for the staff was that once food items were brought to the correct temperature, that they were to be dated and labeled accordingly and discarded after 72 hours. The DM stated dating and labeling was important for the safety of the residents. Food that is not labeled or dated could be expired and could cause illness. In an interview on [DATE] at 4:15 PM The ADM stated his expectation was that food items be dated and labelled when it came off the truck. Items were to be stored properly and when things were opened they were to be labeled. The ADM stated it was the Dietary Manager's responsibility to ensure this was done and that all staff in the kitchen understood and helped with the process. The ADM stated the potential outcome of not dating and labeling was someone could grab something that was out of date and could serve expired food or not know what they were serving. This could cause damage to someone's health. Review of the facility's policy, Food Storage Policy, revised [DATE], revealed, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 2. Refrigerators d. Date, label and tightly seal all refrigerated foods using clean, nonabsorbent, covered containers that are approved for food storage. e. Use all leftovers within 72 hours. Discard items that are over 72 hours old. Review of the Food and Drug Administration Food Code, dated 2022, reflected: ,d+[DATE].11 Food Storage. (A) Except as specified in (B) and (C) of this section, FOOD shall be protected from contamination by storing the FOOD: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination; and (3) At least 15 cm (6 inches) above the floor. (B) FOOD in packages and working containers may be stored less than 15 cm (6 inches) above the floor on case lot handling EQUIPMENT as specified under S ,d+[DATE].122. (C) Pressurized BEVERAGE containers, cased FOOD in waterproof containers such as bottles or cans, and milk containers in plastic crates may be stored on a floor that is clean and not exposed to floor moisture. And ,d+[DATE].16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. N.A. This item may be marked N.A. when there is no ready-to-eat, TCS food prepared on-premise and held, or commercial containers of ready-to-eat, TCS food opened and held, over 24 hours in the establishment. N.O. This item may be marked N.O. when the establishment does handle foods requiring date marking, but there are no foods requiring date marking in the facility at the time of inspection.

Based on observation, interview, and record review the facility failed to dispose of garbage and refuse properly for the facility's main dumpster reviewed for garbage disposal. 1. The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pest and failed to ensure garbage dumpster lids remained closed. This failure could place residents at risk of contracting disease by attracting pest and disease carrying rodents. Findings included: During an observation on 12/13/2023 at 4:40 PM with CNA A of the garbage disposal areas by the trash dumpsters revealed, a busted open trash bag with food debris on the ground, a broken fluorescent bulb (broken glass), and used medical gloves. During an interview on 12/13/23 at 11:06 AM with Maintenance Director A, he stated that he worked at the facility part-time, about 2 hours a day, and was the only one currently in the department. Maintenance Director A stated that he has been coming to this facility to work part-time for 4 weeks, since the full-time maintenance worker got injured and is not coming back. Maintenance Director A stated he hasn't been able to check for trash on the ground, by the dumpsters, as he works mostly on the problems inside the facility buildings. He stated the facility uses ABC Pest & Lawn for pest control and puts a chemical by the trash dumpsters. During an interview with the Regional Director of Plant Operations (RDPO), on 12/14/23 at 12:40 PM, he stated that his expectation was that there be no trash on the ground, and the trash dumpster's lids and side doors should be closed. He said the the dumpster door should be closed, and the trash picked up, because it could attract various animals and pests. The RDPO stated he did not know if the facility had a policy on trash disposal. On 12/14/23 at 2:25pm, an email was received from the Administrator stating the facility does not have a policy regarding who is responsible for maintaining the outside grounds concerning garbage disposal. During an interview on 12/14/23 at 3:50 PM with the Administrator , it was revealed that the maintenance department is responsible to ensure trash is disposed of properly inside the trash dumpsters. The Administrator stated that Maintenance Director B is out injured on worker's compensation and is not coming back. The Administrator stated that the facility has the RDPO who comes by a few hours a day to work. The Administrator stated that the dumpster's lid is usually closed. The Administrator stated the reason it is important to dispose of trash properly and to ensure trash stays in the dumpster, is to keep out pests and rodents, because they posed a contaminiation risk. The Administrator stated that his expectation is that staff dispose of trash into the dumpster, close the lids, and close the doors. Review of the U.S. Public Health Service Food Code, dated 2022, reflected: 5-501.112 Outside Storage Prohibitions. (A) Except as specified in (B) of this section, REFUSE receptacles not meeting the requirements specified under 5-501.13(A) such as receptacles that are not rodent-resistant, unprotected plastic bags and paper bags, or baled units that contain materials with FOOD residue may not be stored outside. (B) Cardboard or other packaging material that does not contain FOOD residues and that is awaiting regularly scheduled delivery to a recycling or disposal site may be stored outside without being in a covered receptacle if it is stored so that it does not create a rodent harborage problem. 5-501.113 Covering Receptacles. Receptacles and waste handling units for REFUSE, recyclables, and returnable(s) shall be kept covered: (A) Inside the FOOD ESTABLISHMENT if the receptacles and units: (1) Contain FOOD residue and are not in continuous use; or (2) After they are filled; and (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT. 6-501.114 Maintaining Premises, Unnecessary Items and Litter. The PREMISES shall be free of: (A) Items that are unnecessary to the operation or maintenance of the establishment such as EQUIPMENT that is nonfunctional or no longer used; and (B) Litter.

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infections for 1 (Residents #64) of 10 residents reviewed for infection control. The facility failed to ensure CNA D washed her hands after barehanded carrying a dirty tray out of a communicable disease isolation room for Resident #242, before barehanded touching Resident #64's bedside table, and barehanded touching Resident #64's call light. The facility failed to ensure CNA D sanitized her hands after exiting Resident #64's room. This failure could place residents at risk of communicable infectious diseases. Findings included: Review of Resident # 242's Admission Record dated 12/13/23, reflected he was a [AGE] year-old male, admitted to the facility 12/11/23 with diagnoses of cellulitis (a serious bacterial infection in the wound), both legs amputated below the knee, rheumatoid arthritis (a disease that affects mostly joints by fluid collection, swelling, and deformity), type 2 diabetes mellitus without complications, and chronic kidney disease. Review of Resident #242 baseline care plan dated 12/11/23, reflected Isolation-Strict single room contact isolation initiated 12/12/23. Goal was to remain on isolation until no longer contagious to others. Interventions were Resident #242 on strict isolation precautions due to a bacterial infection (Acinetobacter baumannii) in the wound. Review of resident #242 orders dated 12/11/23, reflected isolation-Strict Single Room, Strict contact isolation. Review of resident # 64 Admission Record dated 12/11/23, reflected she was a [AGE] year-old female admitted to facility on 11/25/23 with diagnoses of Brain mass, Hypothyroidism- a condition in which the thyroid gland does not produce enough thyroid hormone., Fluid overload, Low potassium, and Unspecified Dementia. Review of Resident #64 annual MDS assessment, dated 11/30/23, reflected BIMS score was 15, indicating no cognitive impairment. Resident required setup and clean up assistance when eating, partial/moderate assistance to transfer, bath, and personal hygiene. Review of resident #64 care plan dated 12/04/23, reflected Activities of Daily Living (ADLs) Self-care Performance Deficit due to Brain Mass. The goal indicated Resident #64 would improve current level of function. The interventions were: assist as needed in aspects of self-care that are problematic to resident. An observation on 12/13/23 at 09:02 AM, revealed CNA F dressed in blue gown, gloves, and mask stood in Resident # 242's doorway holding a tray with dishes. Signage on the door read Stop. Contact Precautions. Everyone Must: Clean hands, including before entering and when leaving the room. Put on gloves before room entry. Put on gown before room entry and discard gown before room exit. Do not wear the same gown and gloves for the care of more than one person. Use dedicated or disposable equipment. Clean and disinfect reusable equipment before use on another person. CNA F asked if someone could take the resident's tray to the cart for her. CNA D walked over to CNA F barehanded (no gloves) and took the tray from isolation room to the cart. No hand hygiene was performed after placing the tray from the isolation room on the cart. Observation and interview on 12/13/23 at 09:05 AM, revealed CNA D entering Resident #64's room. No hand hygiene is performed before entering the room. CNA D moved resident # 64's table closer to her and asked her if she needed anything. She then handed Resident #64 her call light. CNA D exited the room without performing hand hygiene. CNA D said that she forgot to wash her hands. She said that she usually carried hand sanitizer in her pocket but did not have any on her. She said that she could have used the hand sanitizer in the hallway. CNA D said the risk of not washing her hands could cause Resident #64 to get what Resident #242 has. Interview with CNA F on 12/13/23 at 09:09 AM, revealed CNA F had finished assisting Resident #242 with breakfast. She asked for help with the tray because she was not done in Resident #242's room and needed to keep her gown, mask, gloves, and shield (PPE) on. CNA F said she washed her hands after removing the PPE. She said she washed her hands to prevent infection spreading to other residents and to herself. Interview on 12/13/23 at 03:25 PM with the DON revealed new CNA's are trained with RN's and seasoned CNA's for a total of 100 training hours. The DON said that she would not take a tray out of isolation without gloves. She said that she had in-serviced CNA D on Friday the week before survey. Her expectation is that every nursing staff follow standard hand hygiene practices of hand washing with soap and water and using alcohol-based hand rub and PPE requirements. Interview on 12/13/23 at 03:45 pm with ADM revealed all staff members were expected to follow the infection control protocol as indicated. She expected staff to wash hands and to prevent spread of infection. He expected staff to properly wash hands after and before care. He said the risk of staff not washing hands and following standard hand hygiene protocol can cause a spread of infection. Review of the facility policy Infection Prevention and Control Program COVID, revision date 07/23, reflected . .facility will follow Centers for Medicare & Medicaid Services (CMS), Centers for Disease Control and Prevention (CDC) as well as state and local government guidance . Review of the facility policy Handwashing/Hand Hygiene, revision 08/2019, reflected: 1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 3. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. 4. Triclosan-containing soaps will not be used. 5. Residents, family members and/or visitors will be encouraged to practice hand hygiene through the use of fact sheets, pamphlets and/or other written materials provided at the time of admission and/or posted throughout the facility. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: When hands are visibly soiled; and After contact with a resident with infectious diarrhea including, but not limited to infections caused by norovirus, salmonella, shigella and C. difficile. 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after coming on duty; . Before and after direct contact with residents; Before preparing or handling medications Before performing any non-surgical invasive procedures . Before and after handling an invasive device (e.g., urinary catheters, IV access sites); . Before donning sterile gloves; . Before handling clean or soiled dressings, gauze pads, etc.; Before moving from a contaminated body site to a clean body site during resident care; . After contact with a resident's intact skin; . After contact with blood or bodily fluids; . After handling used dressings, contaminated equipment, etc.; . After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; . After removing gloves; . Before and after entering isolation precaution settings; . Before and after eating or handling food; . Before and after assisting a resident with meals; ( .)

Based on observation, interview, and record review the facility failed to ensure food was prepared in a form designed to meet individual needs for one (lunch) of two meals reviewed. Cook C failed to ensure the puree bread was prepared to the desired consistency. This placed residents at risk, who received pureed meals from the kitchen, of choking. Findings included: Record review of the facility's Diet Roster dated 12/13/23 revealed the facility had 5 Residents with a puree diet. An observation on 12/13/23 at 1:32 PM revealed the pureed bread was not the correct consistency. It was thick and lumpy. The consistency was not smooth. The lumps were not hard, but they were firm. An observation and interview on 12/13/23 at 1:40 PM revealed the DM tasted the pureed bread. He stated the pureed bread was pretty thick and should have been looser and smoother. The Dietary Manager stated he did not prepare the pureed bread. He said if he did, he would have added chicken stock to the puree bread to smoothen it. He stated they used the recipe to prepare puree food items and they added either chicken or beef stock. In an interview on 12/13/23 at 2:06 M Cook C stated she went by the recipe to make pureed food items and used either chicken or beef stock. She said she tasted the pureed bread, and it was smooth. She stated as it sat on the steam table, she noticed it began to thicken so she added some broth to it. Cook C stated it was important to ensure the pureed food items were the right consistency so that the residents would not choke. If it is too thick or too thin, they can choke on it, so you must check your consistency of the puree. In an interview on 12/13/23 at 2:30 PM the DM stated it was important to ensure pureed foods were the right consistency for the residents to consume without choking, aspiration, etc. In an interview on 12/13/23 at 4:20 PM the DM stated the facility did not have a policy on making the pureed foods, however they followed the recipe for the pureed item. Review of the Breakfast Bread of Choice Puree Recipe dated 9/27/23 revealed .Puree with a blender or food processor until smooth .The desired thickness should be mashed potato or pudding. There should be no large lumps or particles.

Based on observation, interview, and record review the facility failed to ensure the resident environment was free of accident and hazards as was possible for one resident (Resident #1) of three residents reviewed for accidents and hazards. Driver C failed to follow proper safety measures in securing Resident #1 in the van while driving the resident. An Immediate Jeopardy (IJ) was determined to have existed from [DATE] through [DATE]. The IJ was removed on [DATE] because the facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure placed residents at risk of severe injury or death. Findings include: Record review of Resident #1's face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included altered mental status, kidney cancer, and dialysis. Resident #1 was noted to be her own responsible party. Review of Resident #1's Quarterly MDS assessment, dated [DATE], reflected Resident #1 had adequate hearing, and was able to understand others, and be understood. She had a BIMs score of 12, which indicated moderate cognitive impairment. Resident #1 required limited assistance of one person for bed mobility and walking in the corridor with her walker. Resident #1 was able to move herself around in her wheelchair in the facility but required extensive assistance from one person when leaving the facility. Review of Resident #1's incident report, dated [DATE], for a witnessed fall reflected Resident #1 had fallen in the facility van during transportation. The document reflected the resident said she hit her head, and the resident had a skin tear on her left forearm from the fall, which was treated by a nurse in the facility. Resident #1 was administered pain medication for a slight headache. Her neuro-checks during her initial assessment for this incident, and the following 24 hours reflected no concerns. An interview and observation on [DATE] at 11:18 AM of Driver A revealed he was securing a resident in his wheelchair in the facility van for transportation to a lunch activity. Driver A said he was a temporary driver, and had been trained by watching some videos, and having one of the drivers (Staffing Coordinator), who was present at the time of this interview, showed him how to do everything and was overseeing him. He was observed to fasten the resident's chair in firmly, and to place the lap and shoulder safety belts on Resident #2. An interview and observation on [DATE] at 1:56 PM with Resident #1 revealed she was self-propelling her wheelchair in the common area, near the nurse's station. She had numerous small skin tears visible on her forearms, and she said she got them all the time from bumping into things, and from falling. Resident #1 stated the staff just cleaned them up for her. She said she was in a car accident and had gotten a wound on her arm (slightly visible but healed) but she was okay now. She said the accident was in the facility van, with their Driver C. An interview on [DATE] at 1:41 PM with Driver E revealed Resident #1 had fallen while in the facility van, but it was before she started driving, about a month ago. She said she was only the driver occasionally and was usually a CNA and worked on the floor. She said she did not know all of the circumstances of the fall, but she felt she had adequate training to transport residents safely. An interview on [DATE] at 1:04 PM with the DON revealed Resident #1 had fallen in the van when Driver C was driving her to an appointment. She said she believed it was a self-report, and it should have been one. She said Driver C was straightforward about what happened on the drive, but there was some controversy about what took place leading up to incident, but that was not her area. She said she was called out of a training when Driver C called. Driver C was crying and distraught because a car had cut her off and she had to brake abruptly, which caused Resident #1 to fall from her wheelchair. She said Driver C did not know whether to take Resident #1 to her appointment or bring her back, and they told her to bring the resident back to the facility. The DON said when they arrived at the facility, she was waiting for them, and assessed Resident #1, who had a very gnarly skin tear on her arm. The DON said she personally cleaned up and reapproximated the skin tear, which took her almost an hour. She said there was no actual vehicle accident to call the police or EMS for, and Resident #1 was okay, except for the skin tear. She said though she was not there, and did now know what happened, she was told Resident #1 was not wearing her seatbelt during the drive. The DON said Driver C was no longer a driver, but still worked at the facility. She said the incident had not yet been investigated by the state, and she had expected it sooner than this. An interview on [DATE] at 1:44 PM with Driver D revealed she heard about Resident #1's fall in the facility van. She said she drove the van before this incident but wanted to return to working on the floor as a CNA. She said during the time she drove; Driver C was a backup driver. She said after the incident the Administrator asked her if Driver C had been trained, and she said she had watched both of the required videos (videos demonstrating the restraint systems on both vans). Driver D said she and the Maintenance Director also showed Driver C how to do the restraint systems in the vans. She said she heard Resident #1 was not wearing her seatbelt and fell when the driver braked. She said when she drove Resident #1, the resident had never taken off her own seatbelt, and always fell asleep as soon as they started moving. She said she felt her training was good, and besides the two videos, the Maintenance Director demonstrated everything and went with her on drives before she ever drove by herself. An interview on [DATE] at 2:12 PM with Driver C revealed she was driving when Resident #1 fell in the facility's big van and was the van driver for a month or two. She said a truck flew in front of them and she tapped on the brakes, and Resident #1 scooted. She said nobody ever showed her where the doctors' offices were, or anything, and she was having to figure it out for herself. She said she received some training from Driver D, but she was never shown the seat belts and shoulder belts, only the restraints for the wheelchair itself. She said Driver D took her out to the small van and showed her the wheelchair restraints with her hands and there was no wheelchair involved in the demonstration and the shoulder straps were never brought up. She said she got no training, and nobody rode with her, and because of it, Resident #1 got hurt. Driver C was crying during the interview, and said she did not put the seatbelt on the resident because she was not trained to, and she did not know why she did not think of it, because she knew everyone in a car was required to wear a seatbelt, but she only was told about the chair being locked in. She said she felt cheated out of being able to do the transportation position because she did not get the right training, and she was told she would be able to drive again, but nobody had talked to her about it since. She said there was never any sort of competency checklist, and she was written up. She said she was wearing her own seatbelt, and she never told anyone she did not feel like she had enough training to do the job safely. She said she asked Driver D to show her the shoulder belt once, because she still had not seen the videos, and Driver D showed her in a fast-paced way, and she tried to watch her, but could not remember what she showed her. An interview on [DATE] at 3:18 PM with the Administrator revealed Resident #1 fell in the facility van on [DATE], around 4:00 PM to 4:30 PM. He said when the resident was back in the building, she was very calm, and said she felt it was not Driver C's fault. She had a pretty good skin tear on her arm, U-shaped, and it was reported she bumped her head during the fall. The DON and another nurse assessed her, and the DON treated the skin tear. Her head, and her vitals and neuro-signs were fine. Driver C was a mess, freaking out, with anxiety through the roof. Driver C said another driver had cut them off, and she had not strapped Resident #1 completely, missing the shoulder belt, or maybe the whole thing (lap and shoulder), but he could not remember for sure. He re-walked Driver C through the strapping for the restraint system and had her watch the videos again. He did not know if the resident fell completely or not, but the wheelchair was near the driver's seat, and she might have hit it. Driver C was trained multiple times, by Driver D, and by the Maintenance Director (who was on extended leave with an injury) and watched both of the videos. He said the training consisted of showing her the restraint systems in both vans, which included the restraints for locking the wheelchair to the floor, and how the straps went on the chair and on the person. He said Driver D showed her and he saw the Maintenance Director show her on another occasion. He did not know if either of them rode with her or watched her put a wheelchair in the van. He said before this incident happened, the Maintenance Director and Driver D attended a training by the company that made the restraint systems for both of the vans. When he investigated the incident Driver D told him, Driver C would routinely call on her for instruction on how to do things, she had already shown her. He said he only had documentation of the training Driver C got on [DATE], after the incident, they did not have documentation of the training done before it. He said Driver C was primarily a backup driver until Driver D wanted to return to her CNA duties, and the schedule they had only showed the appointments, but not which driver drove to them. He said he did not personally go on a ride-along, but he did with all the other drivers and that Driver C was upset she did not get that. He said Driver C was a very conscientious CNA, in part because of her anxiety, but they had postponed talking with her about the driving position, because her anxiety might have made her not a good candidate for it. He said he did not report it to HHSC, because at the time he was looking at it like they would look at a fall with a skin tear, and that would not be reportable. An interview on [DATE] at 4:14 PM with Driver D revealed the Maintenance Director had trained both her and Driver C on the small van at the same time, the floor restraints, the lap and shoulder belt, verbally and physically. She said he was also present when she trained Driver C on the large van, the same way. She said there was an empty wheelchair in the van, and she showed her how to use the system on it. She said there was no checklist for the training, but she went through it, and when she asked Driver C if she understood, she said she did, and it seemed pretty simple. An interview on [DATE] at 4:40 PM with Resident #1 revealed she had not been wearing any part of the seatbelt when she fell , and only the chair had been fastened into the van. She also expressed an opinion Driver C was not trained to use the belts, or she would have done so, because she was very protective of the people at the facility. An interview on [DATE] at 4:44 PM with the Staffing Coordinator revealed she had the training video for the restraint system on the large facility van (the van the incident occurred in) on her computer. She said it was one of the two videos everyone who drove the vans were required to watch before they drove. The video viewed during the interview reflected a clear demonstration of how to attach the restraints to the floor and the wheelchair, and how to attach the lap and shoulder belts to the restraint system and place them on the resident. Review of an employee corrective action form, dated [DATE], reflected Driver C was written up for not securing a resident seat belt on a trip. The document reflected one-on-one counsel with the Administrator on safety protocols, and in servicing with the videos. It was noted on the document though the write-up occurred on [DATE]. Review of documents dated [DATE] reflected Documentation of training for Driver C, and included a Transportation Van Driver Safety and Prerequisites Checklist signed on [DATE] by Driver C, indicating she watched two videos and was instructed on the safe loading and restraint of the residents and their wheelchairs in the van, and performed a return demonstration. Review of an in-service form dated [DATE] reflected in-service training by the Administrator with HR detailing HR's responsibility for ensuring the appropriate videos were viewed by new drivers and documentation was placed in their file. It also stated HR would create a checklist for driver training, which would receive final approval from the Administrator. Review of an In-service form dated [DATE] reflected Driver C received driver safety training by the Administrator, and viewed the videos. Review of the facility policy Standards of Care Policy and Procedures for Transporting Residents, revised ,d+[DATE], reflected Personnel accompanying residents must be thoroughly trained in routine and emergency procedures to ensure that every aspect of the transportation process is safety oriented. All employees who drive a company owned van or bus will adhere to these standards and requirements at all times. The following policies and procedures will be followed before, during and after transporting residents in the company-owned bus or van . Loading of Residents . 6. Once all residents have been assisted onto the vehicle, each resident should be fastened into the appropriate safety restraint. This includes seatbelts, shoulder straps or a combination of both. Regarding the residents' rights to refuse restraints does not apply in any moving vehicle. Residents must agree to the use of seatbelts and/or shoulder harnesses or transportation will be refused. Most residents feel more secure with a seatbelt and refusals are seldom a problem . 8. After all residents have been seated on the vehicle, and before the vehicle is moved, the staff member should do a walk-thru to ensure that they are properly secured in seatbelts, shoulder harnesses or other restraining devices The policy included a checklist page, which included signature lines for the staff member and a facility representative: Transportation Aide Acknowledgement: I acknowledge that I have received orientation and training on the use and operation of the facility's bus or van in which I will operate in a safe manner while transporting any resident of this facility to and from this facility for the purpose of any medical appointment or social function or for any other reason as designated by management. I have received copies of the following documents and have read these documents and fully understand their contents and the duties which I must perform: _The Priority Management Driving and Transport Safety Standards. _The Standards of Care Policy and Procedures for Transporting Residents. _The Vehicle Use Acknowledgement Form. _The Verification of Wheelchair Lift Competency and Proficiency (if applicable) _The Daily Vehicle Visual Safety Inspection Log _The Required Items to Be Kept or Maintained on All Company- Owned Buses or Vans _The Transportation Aide Job Description _The Verification of Training in Cardio- Pulmonary Resuscitation (CPR)

Based on observation, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices for four (Residents #8, #9, #7, and #3) of ten residents reviewed for quality of care. 1. The facility failed to ensure Resident #8 did not develop blisters which then worsened to open sores on her back after she was left in a geri-chair for an extended period of time without a barrier between her and the chair. The facility also failed to ensure the correct treatment was applied to Resident #8's blisters on her back when they transitioned to open sores. 2. The facility failed to ensure Resident #9's wound on his heel was being treated properly resulting in him requiring surgical intervention to where he was at risk of losing his foot/leg. 3. The facility failed to follow Resident #7's treatment orders and care plan to ensure that a dressing and treatment was applied to his wound. 4. The facility failed to follow Resident #3's treatment orders and care plan to ensure that previously identified wounds did not worsen. On 08/04/22 at 3:56 PM an immediate jeopardy (IJ) was identified. While the IJ was removed on 08/08/22, the facility remained out of compliance at severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures have the potential to lead to decreased quality of life, serious health outcomes that include physical decline, and hospitalization . Findings included: 1. Review of Resident #8's face sheet, dated 08/06/22, reflected she was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #8's care plan, dated 05/05/22, reflected [Resident #8] was at risk for skin breakdown due to incontinent episodes, confusion, weakness with approaches including: reposition residents every 2 hrs and prn; [Resident #8 has scattered blisters to back [sic] with approaches including: adjust my treatment plan if no healing within 2-4 weeks; [Resident #8] requires assist with ADLs from staff due to weakness and history of fracture and contractures [sic] with approaches including: Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift. Review of Resident #8's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's quarterly MDS assessment, dated 05/07/22, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Review of Resident #8's Departmental Notes reflected: on 08/01/22 LVN R noted N/O'S SCATTERED BLISTERS TO BACK APPLY SKIN PREP Q SHIFT. [WCNP] IN FACILITY TO ASSESS and on 08/05/22 ADON P noted UPPER BACK OPEN AREAS- N/O CLEANSE WITH NS APPLY COLLAGEN AND COVER WITH BORDER FOAM DRSG MWF AND PRN. Review of shower sheets for Resident #8 reflected the following: 06/28/22 showed a circled area at the resident's bottom with a line pointing to it that said open and a circled area to the back of the resident's right calf. 06/30/22 showed no skin problems. 07/14/22 showed a reddened area to the inside of the resident's left leg. 08/02/22 showed a circled area at the resident's left side of the resident's back that said blisters above it and another circled area to the right side of the resident's back said open blisters next to it. An observation and interview on 8/3/2022 at 8:56 AM, visualization of Resident #8's back revealed, reddened areas on the right and left side of the spine mid-way down. Each contained open sores surrounded by skin fragments associated with the rupture of blisters. Two sores noted on the right side measuring 3.5cm x 3.5cm and 4.7cm x 5cm. one sore on the left measuring 6.0cm x 4.0cm . Wound beds are red/raw in appearance with small amount of clear drainage. A white paste-like substance was observed on each of the sores and spread throughout the reddened areas on her back. Resident #8 had nothing covering the open sores, no barrier between her skin and the mattress. ADON P was not aware that the blisters had ruptures and did not have new treatment orders. ADON P stated the white paste like substance was zinc, a protective paste used to protect intact skin. Zinc used on non-intact skin could cause irritation and pain. In a telephone interview on 8/4/2022 at 2:03 PM, WCNP stated she saw Resident #8 on 8/1/2022 and provided orders for skin prep to blisters on the back of Resident #8 and to notify her when blisters opened. She was not aware the blisters had opened until she was called on 8/3/2022 by ADON P. She stated Zinc would not be appropriate for treatment because the skin was broken and it could cause irritation. Review of the facility's policy, revised April 2018, and titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reflected: Section Monitoring, 3. The DON or designee will assess the condition of the residents' skin weekly and notify physician of any new or worsened conditions . 2. Review of Resident #9's face sheet, dated 08/06/22, revealed he was a [AGE] year-old male who admitted to the facility on [DATE] and discharged on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's care plan, dated 05/25/22, reflected as of 07/10/22, [Resident #9] has a stage 3 to left heel with approaches including treat [Resident #7's] ulcer as ordered, monitor [Resident #7's] ulcer for signs of infection. Review of Resident #9's most recent MDS assessment, dated 06/01/22, revealed he had a BIMS score of 15 indicating no cognitive impairment. Review of Resident #9's Departmental Notes reflected: 07/07/22 LVN Q noted .skin to lower legs try and flaky . 07/08/22 LVN Q noted .skin to lower legs dry and flaky . 07/08/22 the RD noted .no pressure wound . with an addendum on 07/18/22 the RD noted .DIABETIC FOOT ULCER L HEEL FOUND ON 7/09 . 07/10/22 RN S noted Resident reported to floor CNAs that heel was bleeding, this nurse was then notified and went to assess left hell. Noted bleeding through sock on left heel, removed sock and cleansed left hell, stage 3 pressure sore noted to back of left heel . 08/01/22 LVN R noted PATIENT WENT TO WOUND CARE AT 2 PM AND WAS SENT TO ER FROM WOUND CARE CENTER Review of shower sheets for Resident #9 reflected the following: 06/17/22 showed a circled area to the back of the resident's right foot with open sore written next to it. 06/20/22 showed two X's to the resident's front legs with a line pointing to them and dry skin, tx in progress 06/24/22 showed two large X's covering the front and back of the resident's trunk of the body and one X at the resident's ankle with a line pointing to it and dry skin written out. 06/27/22 and 06/29/22 both had no skin problems noted. 07/04/22 showed two large X's covering the front and back of the resident's trunk of the body and two X's at the resident's ankles with a line pointing to it and dry skin written out. 07/11/22, 07/13/22, and 07/22/22 had no skin problems noted. Review of Resident #9's Wound Progress Report, dated 07/13/22, reflected: Notified this weekend of pt noticing blood on sock- photo sent of wound- appears a few weeks old (epibole/maceration and large full thickness wound) evaluating today, L heel DFU with and odor noted. A note on the side of the paper read picture from weekend has granulation but today area is dark, trying to form eschar. Review of Resident #9's Wound Progress Report, dated 07/20/22, reflected: wrong tx on wound @ time of rounds- [MEDICATION(S)] blue and silver alginate for a follow up in one to two weeks. Review of Resident #9's wound clinic report, dated 08/01/22, reflected: Pt admitted today for chronic ulceration to left heel of unknown date of origin. First found by facility on July 10, was a chronic appearing ulcer at that time with granulation tissue and epibole to the edges .Of note, the wound deteriorated significantly this weekend, with redness extending beyond the patient's knee . Review of the Resident #9's surgery operative report, dated 08/02/22, reflected: .patient presented to the wound care clinic yesterday .on evaluation [Resident #9] had a significantly necrotic wound to the posterior aspect of the left calcaneus .discussed need for removal of nonviable tissue in the calcaneus with high risk of limb loss . 3. Review of Resident #7's face sheet, dated 08/06/22, reflected he was an [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's care plan, dated 01/18/22, reflected: as of 07/27/22 [Resident #7] has a surgical wound to [his] penis with approaches including [Resident #7] need[s] treatment as ordered by [his] physician, protect [his] area from further injury, monitor for changes in [his] skin status that may indicate worsening of [his] skin tear/laceration and notify the physician. Review of Resident #7's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's quarterly MDS assessment, dated 06/10/22, reflected he had a BIMS score of 06, indicating severe cognitive impairment. Record review of Resident #7's Wound Progress Note dated 7/20/2022 WCNP notes No product has been used since last weeks rounds (dressing not changed as ordered). The prescribed product was provided by the WCNP and found unopened on 7/20/2022. WCNP noted no anchor on foley catheter. An observation and interview 8/3/2022 at 09:54 AM visualization of Resident #7's torso, revealed the absence of a dressing on the penis. The anterior side of the penis was flesh colored, visualization of the underside of the penis revealed the absence of skin from the head to the base of the penis, the mucosal tissue appears moist, with a dark reddish/purple color. A defect is noted within the mucosal tissue with well-defined borders; the defect measures 7.50cm x 2.0cm x 0.10cm. ADON P stated the trauma was caused by the pulling of the foley catheter when the resident was moved without securing the catheter tubing. Resident #7 does not have sensation for pain or discomfort below the waist. The injury was identified by the blood on the bed. 4. Review of Resident #3's, face sheet, dated 8/6/2022, reflected she was a [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #3's quarterly MDS assessment dated [DATE], reflected she had a BIMS score of 03 indicating severe cognitive impairment. Review of Resident #3's care plan, dated 10/27/2020, reflected [Resident #3] was at risk for skin tears/bruises related to fragile skin and combativeness during care with approaches including: assess/monitor skin q shift as of 7/13/2022 [Resident #3] has right shin skin tear with approaches including monitor for changes in skin status that may indicate worsening of my skin tear/laceration and notify the physician adjust treatment plan if no healing within 2 - 4 weeks. As of 7/27/2022 [Resident #3] has a venous stasis ulcer right lower leg. Wound began as a skin tear on 2/25/2022 with approaches including Use pillows or other supportive/protective devices to assist with positioning, Refer to wound specialist or wound clinic for evaluation, Provide wound care as ordered by physician and NP. Review of Residents #3's August 2022 Physicians Orders reflected: as of 8/5/2022 leave silver Polymen (dressing) in place to r leg until 8/11/2022 if soiled or dislodged notify WCNP. Review of Resident #3's Departmental Notes reflected: on 7/27/2022 Skin tear/right lateral shin//wound rounds performed with WCNP wound treatment done with Silver Polymen and to stay in place until 8/3/2022. Nurse to notify WCNP if Tx wet or dislodged. Observation and interview on 8/3/2022 at 11:15 AM, Resident #3's dressing was observed, loosely on her leg, near the ankle and not the shin as prescribed. The upper portion of the wound was exposed. Upon removal of the dressing the wound is measured as 7.5cm x 6.5cm x 0.10cm, with 30% new growth and 70% granulation tissue (precursors to new tissue). ADON P states the wound has deteriorated since her last visit. Review of a sheet of paper provided by the facility titled Current Wounds on 08/02/22 reflected the following : [Resident #3]?RLE DRESSSING-SKIN TEAR [Resident #8]?SKIN PREP TO TOE, L LATERAL LOWER LEG STAGE 3, SACRAM STAGE 3, L LATERAL FOOT STAGE 3, LEFT FOREARM, SCATTERED BLISTERS TO BACK [Residents #7 and #9 were not listed and the list did not specify if the wounds were pressure related or not.] In a confidential interview with facility employee Z revealed they had noticed over the last few weeks that skin assessments were not being completed because staff did not have time during their shift, wounds were not being treated because there were no supplies, and wounds were becoming worse because of all of this. They said that it was difficult for the agency staff to learn the facility's EHR software and they themselves did not know the EHR software very well either. They said they had already mentioned their concerns to the Administrator but that he did not do anything about it. In a confidential interview with facility employee Y revealed the facility had lost a lot of staff the last few weeks and residents were suffering because they were not receiving the care they needed . They said they started to notice that the staff were not tracking wounds, providing treatments for wounds, and residents were developing new pressure ulcers that were worsening. They said the staff did not have the time during their shift to complete their wound care treatments, complete skin assessments, and did not have the supplies necessary to care for wounds. They said they had already told the Administrator about their concerns, and nothing changed. In a confidential interview with facility employee X revealed the nurses at the facility were not completing skin assessments or wound treatments, so residents' wounds were getting worse and worse. They said the facility did not have supplies to treat residents' wounds either. They said Resident #9's wound recently worsened to the point that he had to go to the hospital and was at risk of losing his leg due to an infection caused by the facility not properly treating his wound. They also said that Resident #8 was left in a geri-chair for an extended period of time resulting in her developing blisters to her back. They said the facility staff were reporting that there were not any wound care supplies in the facility and that staff did not have the time to treat the wounds or complete skin assessments. In a confidential interview with facility employee W revealed there have been multiple residents developing new or worsened wounds because staff did not have the supplies they needed to treat the wounds. They said more recently, Resident #8 was left in a geri-chair for an extended period of time and from that developed blisters to their back. They said they had told the Administrator about their concerns but that nothing has changed. In a confidential interview with facility employee V revealed they had noticed the facility did not have necessary supplies to treat resident's wounds. They said it was often that they would have to stay late to complete their skin assessments and wound treatments but there were times they could not be done. They said between the lack of supplies and time during their shift residents' wounds went untreated. They said they tried their best to piece together wound treatments based on what they could find but they knew it would not be the right treatment . In a confidential interview with facility employee U revealed Resident #8 was left in a geri-chair for an extended period of time on 07/31/22 and developed blisters. They said Resident #8 was wearing a hospital gown that was left open so there was not a barrier between her skin and the material of the chair. They said that Resident #8 was also soaking wet and urine was dripping from the chair. They said the facility was understaffed and there was not enough time during their shift to complete skin assessments and wound treatments so now wounds were getting worse. They said the facility was also missing necessary supplies to treat the wounds so it was difficult following doctor's orders completely. They said they would either have to go without treating a resident's wound or using the incorrect treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In a confidential interview with facility employee T revealed she was rounding with the previous shift when she was told that Resident #8 had been in a chair all day and developed blisters on her back. They said it was odd because normally Resident #8 was kept in bed and would be repositioned often since that was better for the care of her wounds that she had. They said they noticed Resident #9's heel was starting to smell at the site of his wound on Wednesday (07/27/22) and the wound had not changed by Friday (07/29/22). They said Resident #9 reported he felt like this employee was the only one who ever cared for the wound, that none of the other staff were treating it. In an interview on 08/04/22 at 9:00 AM with the WCNP revealed she was called on 07/10/22 and told by RN S that there was blood on Resident #9's sock. The WCNP said RN S told her Resident #9 had admitted to the facility in May but recently transferred to her hall and she found this new wound. The WCNP said the wound was a stage three pressure wound so she gave treatment orders. The WCNP said she rounded on 07/13/22 in the facility and found Resident #9 without a dressing on his wound and it was now a deep tissue injury. The WCNP said when she spoke with the staff at the facility, they told her they did not have the products to treat Resident #9's wound, so she provided it for them. The WCNP said she went back to the facility on [DATE] and the wound looked to be improving. The WCNP said she received a call from LVN R on 07/21/22 that there was no dressing to Resident #9's wound, that there was a bad smell, and the wound was rough looking. The WCNP said she instructed LVN R to let her know if the wound got worse. The WCNP said she saw Resident #9 in clinic on 08/01/22 and sent him straight to the hospital based on the severity of his wound at that point. The WCNP said Resident #9 was at risk of losing his foot and/or leg depending upon what the surgeon found during surgery. In an interview on 08/04/22 at 12:03 PM with the ADON revealed she did not know Resident #9 had a wound on his heel. The ADON said she expected staff to notify her of when there were any new or worsening wounds found on residents. The ADON said because the facility was using so much agency it was difficult to get report from them on what was happening with the residents. The ADON said she was recently notified by LVN Q that Resident #8 had blisters to her back and the WCNP was contacted and gave treatment orders. The ADON said she was told by LVN Q that Resident #8 was left up for too long which caused the blisters because it was not safe for her. The ADON said she felt it was because of the facility using agency to staff the building and the agency staff were not familiar with the residents, including Resident #8. The ADON said she was not aware that staff were not providing treatments to residents' wounds, only that they did not have the supplies to follow the treatment orders. The ADON said she had been discussing the lack of supplies and inadequate staff with the Administrator and nothing had changed. The ADON said staff were supposed to be doing weekly skin assessments and document them in the facility's EHR under the WAM. The ADON said she herself was not familiar with the WAM since she had not received adequate training on it she also could not train others. The ADON said since she was not familiar with the EHR there was no way for her to be tracking that staff were completing the skin assessments. In an interview on 08/04/22 at 1:00 PM with the Administrator revealed he did not recall anything related to Resident #7 other than his name. The Administrator said he did not recall anything related to Resident #8 other than her name. The Administrator said he had heard a story about a resident from the WCNP earlier in the week, but that she did not mention a resident by name. The Administrator said he deduced on his own that it was Resident #9 and that the resident had left the facility to go to the wound clinic, and from there was admitted to the hospital. The Administrator said he was told during a conversation with the WCNP that there was a concern with a resident on the 200-hall with two CNA's who did not do their jobs. The Administrator said the WCNP expressed that a resident was left unattended for too long. The Administrator said the WCNP also told him she had been providing wound care and treatment supplies to the facility, but he did not have a way to verify that. The Administrator said no staff had mentioned to him that they needed supplies for wound care except for when the ADON mentioned needing some calcium alginate or something like that which was obtained from a sister facility. The Administrator said he was not sure when the ADON mentioned this, but it was before Monday and his conversation with the WCNP. The Administrator said all nurses have access to the facility's EHR and were responsible for completing skin assessments. The Administrator said he expected agency staff to operate the same as regular staff. The Administrator said he was not sure if staff were familiar with WAM or not. The Administrator said he expected staff to do the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator said the facility did not currently have a DON, so the ADON was responsible for ensuring staff were completing skin assessments, completing treatments for residents, correct treatments were being applied, and supplies were available for the treatments. The Administrator said there was only so much that one nurse could do during their shift. The Administrator said he had not been notified that staff were not doing resident skin assessments or wound treatments. Review of the facility's policy, revised April 2018, and titled Skin Breakdown- Clinical Protocol reflected: Assessment and Recognition: 3. In addition, the nurse shall describe and document/report the following wound conditions when identified within the EMR: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. F. When the wound was identified (for example, admit or facility acquired) .Monitoring: 3. The DON or designee will assess the condition of the residents' skin weekly and notify physician of any new or worsened conditions; this assessment will be documented in the EMR .Documentation: 2. Weekly assessment of resident skin condition will be documented in Wound Assessment Manager and EMR (electronic medical record). 3. Newly identified skin concerns will be added to the Wound Assessment Manager and EMR upon identification and updated weekly with assessments recording the progress of the skin concern. On 08/04/22 at 3:56 PM the Administrator was informed of the IJ and were given the IJ template. The facility's POR was accepted on 08/05/22 at 2:08 PM and reflected the following: [FACILITY NAME] Facility initiated full skin sweep on August 4, 2022. Sweep continues on August 5. Sweep conducted by ADON and designee nurses. If new or worsened skin conditions are identified Administrative Nurse will ensure proper physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Data regarding new/worsened findings to be included here, including corrections to orders and other facility actions. Administrative Nurse conducted in-service with all facility nurses, and agency nurses in facility, regarding proper completion of skin assessment including reporting findings to ADON, DON, or Designee on August 4 and August 5, 2022. New hire nurses and agency nurses that have not been trained will not be allowed to start a shift prior to receiving the same in-service by Administrative Nurse or designee. Administrative Nurses will monitor completion of skin assessments daily (for day before), according to the published weekly skin assessment schedule. Any missed assessment, or area of incompleteness, will be addressed immediately and corrected with education and/or disciplinary action. Administrative nurses/designee will audit the nurse MAR/TARs daily to ensure that treatments are completed as ordered. Daily audits will continue for 2 weeks, or later if deemed necessary by QAPI. The administrative nurses will report the results of their audits in the morning clinical meeting. Administrative Nurse/Designee will conduct rounds daily for 2 weeks to lay eyes on the care provided to ensure treatments are provided properly. Thereafter schedule of rounds to be set and monitored by QAPI. Non-compliance will be addressed immediately with education, corrections, and/or disciplinary action. Findings from the rounds will be reported to the Administrator. Administrative nurse conducted in-service on August 4 and 5 to all CNAs and nurses in facility (agency and facility) regarding properly strapping catheter. All facility CNAs and nurses, not yet trained, will not be allowed to start a shift at facility prior to receiving same training by Administrative Nurse or designee. New hire CNAs/nurses and agency CNAs/nurses that have not been trained will not be allowed to start a shift prior to receiving the same in-service by Administrative Nurse or designee. Administrative Nurse/designee will round daily for 2 weeks to monitor proper placement of catheter straps and ensure training is effective. Non-compliance will be addressed immediately with education and/or disciplinary action. Findings of monitoring will be reported to the Administrator. Administrator/designee will ensure all staff in-services are complete. The following interviews and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Review of skin assessments revealed that all residents had completed skin assessments notating any new, existing, or worsened wounds or skin concerns as of 08/06/22. Review of treatment orders for any wounds or skin concerns in the facility revealed they matched what had been identified on the skin assessments completed as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's skin assessment policy and schedule as well as how to complete a skin assessment as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on treating pressure ulcers and skin breakdowns as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on skin tears, abrasions, and minor breaks in the skin as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on checking catheters and [catheter] straps as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on wound management as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on wound care as of 08/06/22. Interviews were conducted with staff across multiple shifts from 08/05/22 to 08/08/22 including: nine LVN's, twelve CNA's, the ADON, and the Administrator. They were all able to verbalize the appropriate understanding of: skin assessments, the schedule for completing skin assessments, the importance of documenting and reporting changes in a residents' skin, providing wound care, and calling the doctor if the necessary supplies were not available in the facility, checking to ensure a catheter strap was in place for any residents who use catheters. Observations of wound care from 08/06/22 to 08/08/22 revealed staff were treating residents' wounds. Observations of the facility's treatment cart on 08/08/22 revealed it had the necessary supplies needed to care for the resident's wounds in the facility. Observations of Resident #7 revealed he had a leg strap in place for his catheter on 08/08/22. An Immediate Jeopardy (IJ) was identified on 08/04/22 at 3:56 PM. While the IJ was removed on 08/08/22, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for five (Residents #1, #2, #6, #4, and #10) of ten residents reviewed for pressure ulcers. 1. The facility failed to follow Resident #1's treatment orders and care plan to ensure that new wounds did not develop and previously identified wounds did not worsen. 2. The facility failed to follow Resident #2's treatment orders and care plan to ensure that a dressing and treatment was applied to her wound. 3. The facility failed to follow Resident #6's treatment orders and care plan to ensure that new wounds did not develop. 4. The facility failed to follow Resident #4's treatment orders and care plan to ensure that new wounds did not develop. 5. The facility failed to follow Resident #10's treatment orders and care plan to ensure that new wounds did not develop. These failures placed residents with skin breakdown at risk of pain, worsening of wounds, infection, emotional distress, harm, or hospitalization . On 08/04/22 at 3:56 PM an immediate jeopardy (IJ) was identified. While the IJ was removed on 08/08/22, the facility remained out of compliance at severity level of actual harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. Findings included: 1. Review of Resident # 1's face sheet, dated 08/06/2022, reflected he was an [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's quarterly MDS dated [DATE], reflected he had a BIMS score of 11, indicating moderate cognitive impairment . Review of Resident #1's care plan, dated 12/23/2021 reflected as of 6/18/2022, [Resident #1] has MASD on the right buttock with approaches including: reposition q2hrs and PRN monitor for s/s of infection; redness, pain, swelling, foul odor, increase in drainage treatments as ordered. As of 7/27/2022, [Resident #1] has a stage 2 pressure ulcer to right buttock that began as MASD with approaches including Report changes in skin status to physician/NP assist PRN to reposition/shift weight to relieve pressure, provide wound care as ordered per physician/NP, monitor for changes in skin status that may indicate worsening of my pressure ulcer and notify the physician. [Resident #1] requires assist with ADLs from staff due to weakness and recent [CONDITION(S)] with approaches including: Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift. Review of Resident # 1's July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's departmental notes reflected: pressure ulcer/left buttock/zinc cream to bilateral buttocks qshift - Encourage positioning Q2hours and PRN. Observation and interview on 8/3/2022 at 10:12 AM, ADON P immediately identified a new wound on Resident #1's left buttock. Described the wound as a stage 2 measured at 4.50cm x 4.0cm x 0.10cm 50% granulation (precursor to new tissue growth) tissue and 50% epithelial (new tissue growth) no drainage noted. Treatment orders pending; Resident #1 had an existing pressure wound on the right buttock, measured at 10 x 7.0cm x 0.10cm states this is larger than the previous weeks measurement and includes the skin that was damaged by the moisture. ADON P believes the staff was not changing the wet dressing after the shower, resulting in the softening of the skin under the wet dressing. 2. Review of Resident #2's face sheet, dated 8/2/2022, reflected he was a [AGE] year-old male who admitted to the facility on [DATE]. His diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #2's MDS assessment dated [DATE], reflected he had a BIMS score of 15 indicating cognitive intact. Review of Residents #2's care plan, dated 7/12/2022, reflected [Resident #2 was admitted with an unstageable pressure to the right buttock] with approaches including: Monitor for changes in my skin status which may indicate worsening or my pressure ulcer and notify the physician; Weekly evaluation of wound healing; Provide wound care as ordered by physician/Np. Review of Resident #2's July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Apply nickel thick layer of Santyl. Cover with bordered foam. Change daily and PRN. Observation and interview on 8/3/2022 at 1:54 PM, Resident #2's brief was removed, no dressing was noted on the residents' skin or in the brief. Red/bloody drainage was noted in the brief. Wound measured at 3.0cm x 1.0cm x0.10cm. Wound described by ADON P as 100% slough with reddish drainage. ADON P stated the wound is larger than when she saw it last week. 3. Review of Residents #6's face sheet dated 08/02/2022, reflected she was an [AGE] year-old female who admitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents #6's quarterly MDS assessment dated reflected she had a BIMS score of 03, indicating severe cognitive impairment. Review of Resident #6's care plan, dated 8/31/2021, reflected as of 7/27/2022 [Resident #6] had an unstageable pressure ulcer to the right heel. With approaches including: Referral to the wound clinic, Report changes in skin status to physician/NP Assist PRN to reposition/shift weight to relieve pressure, Minimize pressure over boney proinences (sic), provide wound care as ordered by physician/NP as of 8/3/2022 [Resident #6] has a DTI on the left heel with approaches including: treatments as ordered, monitor for s/s of infection: redness, pain, swelling, foul odor, increase in drainage, assist with repositioning q2hrs and PRN. [Resident #6] has a stage 1 DTI left 5 toe with approaches including: Encourage me to weight shift while sitting up in chair, weekly evaluation of wound healing. Review of Resident #6's July 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 8/3/2022 at 2:43 PM, Resident wearing heel protection on both heels. R heel has an unstageable pressure ulcer measured at 3.0cm x 3.5cm x 0.2 described by ADON P as 20% granulation tissue and 80% slough/eschar. The surrounding tissue was described as mushy color does not return to the area when pressure is applied and removed. New DTI noted to left heel, measured at 0.1 x 0.1 color to the area slow to return when pressure applied and removed. 4. Review of Resident #4's face sheet dated 08/02/2022, reflected she was an [AGE] year-old female who admitted to the facility 12/24/2022. Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's quarterly MDS assessment dated [DATE], reflected that she had a BIMS score of 15, indicating intact cognition . Review of Resident #4's care plan dated 12/24/2021 reflected as of 8/3/2022 an unstageable Pressure ulcer to the Left heel. With approaches including: wound care as ordered by the physician, floating heels on a pillow, monitor for changes in my skin status that may indicate worsening of my pressure ulcer and notify the physician. Review of Departmental Notes reflected: On 8/4/2022 at 2:25 PM a N/O for low air loss mattress for offloading and wound prevention. On 8/3/2022 8:45 PM, Pressure Ulcer/left heel .seen for wound rounds new unstageable to left heel skin prep applied and heel protector applied. On 8/3/2022 8:33 PM Pressure Ulcer/right heel, r medial heel stage (sic) measured at 2.0cm x 1.5cm Observation and interview on 8/3/2022 at 2:30 PM, examination of Resident #4's heel revealed, a new pressure ulcer on the left heel. Resident was wearing foam heel protectors. The ulcer resembles a callous that has been peeled back from the foot. The tissue underneath the torn skin is black (eschar) in color and measured 1.5cm x 4cm no drainage noted. 5. Review of Resident # 10's face sheet dated 8/6/2022, revealed she was an [AGE] year-old female who admitted to the facility 7/19/2022. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Residents #10's care plan dated 7/19/2022 revealed Resident #10 was at risk for skin breakdown with approaches including: avoidance of restrictive clothing. Review of Resident #10's August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #10's Departmental Notes revealed as of 8/4/2022: Pressure Ulcer/sacrum applied wound care on 8/3 bilateral sacral unstageable wound. Observation of wound care on 8/3/2022 at 3:00 PM, Upon visualization of Resident #10's back, a dressing was noted on the left buttock, a new reddish/purplish discoloration noted on the right side and within the sacral area. The redness and discoloration covers a large space joining the sacral region and the tops of each buttock. No opening is noted on the right buttock or sacral area. Wound was classified by ADON P as a DTI, because the skin was intact. The wound measured at 4.50cm x 11.50cm. ADON P stressed the importance of keeping Resident #10's skin dry, she described the skin in the sacral region as macerated (damaged by moisture), which placed Resident #10 at an increased risk for skin breakdown. Review of a sheet of paper provided by the facility titled Current Wounds on 08/02/22 reflected the following : [Resident #10]?BUTTOCK WOUND, RIGHT HIP SURGICAL WOUND [Resident #6]?LEFT GREAT TOE OPEN WOUND, RIGHT HEEL UNSTAGEABLE [Resident #4]?RIGHT HEEL STAGE 3 [Resident #2]?R BUTTOCK UNSTAGEABLE, GROIN CANDIDIASIS, R LAT ANKLE WOUND, AQUAPHOR TO BLE, R LATERAL ANKLE UNSTAGEABLE [Resident #1]?STAGE 2 RIGHT BUTTOCK In a confidential interview with facility employee Z revealed they had noticed over the last few weeks that skin assessments were not being completed because staff did not have time during their shift, wounds were not being treated because there were no supplies, and wounds were becoming worse because of all of this. They said that it was difficult for the agency staff to learn the facility's EHR software and they themselves did not know the EHR software very well either. They said they had already mentioned their concerns to the Administrator but that he did not do anything about it. In a confidential interview with facility employee Y revealed the facility had lost a lot of staff the last few weeks and residents were suffering because they were not receiving the care they needed . They said they started to notice that the staff were not tracking wounds, providing treatments for wounds, and residents were developing new pressure ulcers that were worsening. They said the staff did not have the time during their shift to complete their wound care treatments, complete skin assessments, and did not have the supplies necessary to care for wounds. They said they had already told the Administrator about their concerns, and nothing changed. In a confidential interview with facility employee X revealed the nurses at the facility were not completing skin assessments or wound treatments, so residents' wounds were getting worse and worse. They said the facility did not have supplies to treat residents' wounds either. They said Resident #9's wound recently worsened to the point that he had to go to the hospital and was at risk of losing his leg due to an infection caused by the facility not properly treating his wound. They also said that Resident #8 was left in a geri-chair for an extended period of time resulting in her developing blisters to her back. They said the facility staff were reporting that there were not any wound care supplies in the facility and that staff did not have the time to treat the wounds or complete skin assessments. In a confidential interview with facility employee W revealed there have been multiple residents developing new or worsened wounds because staff did not have the supplies they needed to treat the wounds. They said more recently, Resident #8 was left in a geri-chair for an extended period of time and from that developed blisters to their back. They said they had told the Administrator about their concerns but that nothing has changed. In a confidential interview with facility employee V revealed they had noticed the facility did not have necessary supplies to treat resident's wounds. They said it was often that they would have to stay late to complete their skin assessments and wound treatments but there were times they could not be done. They said between the lack of supplies and time during their shift residents' wounds went untreated. They said they tried their best to piece together wound treatments based on what they could find but they knew it would not be the right treatment . In a confidential interview with facility employee U revealed Resident #8 was left in a geri-chair for an extended period of time on 07/31/22 and developed blisters. They said Resident #8 was wearing a hospital gown that was left open so there was not a barrier between her skin and the material of the chair. They said that Resident #8 was also soaking wet and urine was dripping from the chair. They said the facility was understaffed and there was not enough time during their shift to complete skin assessments and wound treatments so now wounds were getting worse. They said the facility was also missing necessary supplies to treat the wounds so it was difficult following doctor's orders completely. They said they would either have to go without treating a resident's wound or using the incorrect treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . In a confidential interview with facility employee T revealed she was rounding with the previous shift when she was told that Resident #8 had been in a chair all day and developed blisters on her back. They said it was odd because normally Resident #8 was kept in bed and would be repositioned often since that was better for the care of her wounds that she had. They said they noticed Resident #9's heel was starting to smell at the site of his wound on Wednesday (07/27/22) and the wound had not changed by Friday (07/29/22). They said Resident #9 reported he felt like this employee was the only one who ever cared for the wound, that none of the other staff were treating it. In an interview on 08/04/22 at 12:03 PM with the ADON revealed she was not aware that staff were not providing treatments to residents' wounds, only that they did not have the supplies to follow the treatment orders. The ADON said she had been discussing the lack of supplies and inadequate staff with the Administrator and nothing had changed. The ADON said staff were supposed to be doing weekly skin assessments and document them in the facility's EHR under the WAM. The ADON said she herself was not familiar with the WAM since she had not received adequate training on it she also could not train others. The ADON said since she was not familiar with the EHR there was no way for her to be tracking that staff were completing the skin assessments. In an interview on 08/04/22 at 1:00 PM with the Administrator revealed no staff had mentioned to him that they needed supplies for wound care except for when the ADON mentioned needing some calcium alginate or something like that which was obtained from a sister facility. The Administrator said he was not sure when the ADON mentioned this, but it was before Monday and his conversation with the WCNP. The Administrator said all nurses have access to the facility's EHR and were responsible for completing skin assessments. The Administrator said he expected agency staff to operate the same as regular staff. The Administrator said he was not sure if staff were familiar with WAM or not. The Administrator said he expected staff to do the treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator said the facility did not currently have a DON, so the ADON was responsible for ensuring staff were completing skin assessments, completing treatments for residents, correct treatments were being applied, and supplies were available for the treatments. The Administrator said there was only so much that one nurse could do during their shift. The Administrator said he had not been notified that staff were not doing resident skin assessments or wound treatments. Review of the facility's policy, revised April 2018, and titled Skin Breakdown- Clinical Protocol reflected: Assessment and Recognition: 3. In addition, the nurse shall describe and document/report the following wound conditions when identified within the EMR: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. F. When the wound was identified (for example, admit or facility acquired) .Monitoring: 3. The DON or designee will assess the condition of the residents' skin weekly and notify physician of any new or worsened conditions; this assessment will be documented in the EMR .Documentation: 2. Weekly assessment of resident skin condition will be documented in Wound Assessment Manager and EMR (electronic medical record). 3. Newly identified skin concerns will be added to the Wound Assessment Manager and EMR upon identification and updated weekly with assessments recording the progress of the skin concern. On 08/04/22 at 3:56 PM the Administrator was informed of the IJ and were given the IJ template. The facility's POR was accepted on 08/05/22 at 2:08 PM and reflected the following: [FACILITY NAME] Facility initiated full skin sweep on August 4, 2022. Sweep continues on August 5. Sweep conducted by ADON and designee nurses. If new or worsened skin conditions are identified Administrative Nurse will ensure proper physician order [MEDICAL RECORD OR PHYSICIAN ORDER] Data regarding new/worsened findings to be included here, including corrections to orders and other facility actions. Administrative Nurse conducted in-service with all facility nurses, and agency nurses in facility, regarding proper completion of skin assessment including reporting findings to ADON, DON, or Designee on August 4 and August 5, 2022. New hire nurses and agency nurses that have not been trained will not be allowed to start a shift prior to receiving the same in-service by Administrative Nurse or designee. Administrative Nurses will monitor completion of skin assessments daily (for day before), according to the published weekly skin assessment schedule. Any missed assessment, or area of incompleteness, will be addressed immediately and corrected with education and/or disciplinary action. Administrative nurses/designee will audit the nurse MAR/TARs daily to ensure that treatments are completed as ordered. Daily audits will continue for 2 weeks, or later if deemed necessary by QAPI. The administrative nurses will report the results of their audits in the morning clinical meeting. Administrative Nurse/Designee will conduct rounds daily for 2 weeks to lay eyes on the care provided to ensure treatments are provided properly. Thereafter schedule of rounds to be set and monitored by QAPI. Non-compliance will be addressed immediately with education, corrections, and/or disciplinary action. Findings from the rounds will be reported to the Administrator. Administrative nurse conducted in-service on August 4 and 5 to all CNAs and nurses in facility (agency and facility) regarding properly strapping catheter. All facility CNAs and nurses, not yet trained, will not be allowed to start a shift at facility prior to receiving same training by Administrative Nurse or designee. New hire CNAs/nurses and agency CNAs/nurses that have not been trained will not be allowed to start a shift prior to receiving the same in-service by Administrative Nurse or designee. Administrative Nurse/designee will round daily for 2 weeks to monitor proper placement of catheter straps and ensure training is effective. Non-compliance will be addressed immediately with education and/or disciplinary action. Findings of monitoring will be reported to the Administrator. Administrator/designee will ensure all staff in-services are complete. The following interviews and record reviews were conducted to verify the implementation of the facility's Plan of Removal and revealed the following: Review of skin assessments revealed that all residents had completed skin assessments notating any new, existing, or worsened wounds or skin concerns as of 08/06/22. Review of treatment orders for any wounds or skin concerns in the facility revealed they matched what had been identified on the skin assessments completed as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's skin assessment policy and schedule as well as how to complete a skin assessment as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on treating pressure ulcers and skin breakdowns as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on skin tears, abrasions, and minor breaks in the skin as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on checking catheters and [catheter] straps as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on wound management as of 08/06/22. Review of an in-service reflected staff had been educated and trained on the facility's policy on wound care as of 08/06/22. Interviews were conducted with staff across multiple shifts from 08/05/22 to 08/08/22 including: nine LVN's, twelve CNA's, the ADON, and the Administrator. They were all able to verbalize the appropriate understanding of: skin assessments, the schedule for completing skin assessments, the importance of documenting and reporting changes in a residents' skin, providing wound care, and calling the doctor if the necessary supplies were not available in the facility, checking to ensure a catheter strap was in place for any residents who use catheters. Observations of wound care from 08/06/22 to 08/08/22 revealed staff were treating residents' wounds. Observations of the facility's treatment cart on 08/08/22 revealed it had the necessary supplies needed to care for the resident's wounds in the facility. Observations of Resident #7 revealed he had a leg strap in place for his catheter on 08/08/22. An Immediate Jeopardy (IJ) was identified on 08/04/22 at 3:56 PM. While the IJ was removed on 08/08/22, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not immediate jeopardy and a scope of pattern because the facility was still monitoring the effectiveness of their Plan of Removal.

Based on observation, interview, and record review, the facility failed to ensure residents were free from neglect for two (Resident #7 and Resident #8) of five residents were reviewed for neglect. 1. The facility failed to ensure Resident #8 was not left in a geri-chair for an extended period of time which resulted in her developing blisters. The facility also failed to notify and obtain orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2. The facility failed to ensure Resident #7 utilized a leg strap to decrease the tension from his indwelling foley catheter after it had to be surgically placed from when it was pulled out on 06/29/22. These failures placed residents at risk of abuse, neglect, decline in health, and being displaced or hospitalized . Findings include: Review of the facility's policy, revised December 2016, and titled Abuse Prevention Program reflected: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms .As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of the facility's policy, revised March 2018, and titled Abuse and Neglect- Clinical Protocol reflected: 2. 'Neglect,' as defined at [symbol] 483.5, means 'the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress.' 1. Review of Resident #8's face sheet, dated 08/06/22, reflected she was an [AGE] year-old female who originally admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of Resident #8's care plan, dated 05/05/22, reflected [Resident #8] was at risk for skin breakdown due to incontinent episodes, confusion, weakness with approaches including: reposition residents every 2 hrs and prn; [Resident #8 has scattered blisters to back [sic] with approaches including: adjust my treatment plan if no healing within 2-4 weeks; [Resident #8] requires assist with ADLs from staff due to weakness and history of fracture and contractures [sic] with approaches including: Provide level of support to complete dressing, toilet use, personal hygiene, and bathing needs q shift. Review of Resident #8's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's quarterly MDS assessment, dated 05/07/22, reflected she had a BIMS score of 03, indicating severe cognitive impairment. Review of Resident #8's shower sheet dated 8/2/2022, reflected open blisters on the back, on the right side , identified by CNA N. In an interview on 8/6/2022 at 11:15 CNA N, stated that she documented on the shower sheet open blisters on the back of Resident #8. CNA N was not certain she reported the findings verbally to the nurse. Review of Resident #8's Departmental Notes reflected: on 08/01/22 LVN R noted N/O'S SCATTERED BLISTERS TO BACK APPLY SKIN PREP Q SHIFT. [WCNP] IN FACILITY TO ASSESS and on 08/05/22 ADON P noted UPPER BACK OPEN AREAS- N/O CLEANSE WITH NS APPLY COLLAGEN AND COVER WITH BORDER FOAM DRSG MWF AND PRN. In a confidential interview with facility employee X revealed the nurses at the facility were not completing skin assessments or wound treatments, so residents' wounds were getting worse and worse. They said the facility did not have supplies to treat residents' wounds either. They also said that Resident #8 was left in a geri-chair for an extended period of time resulting in her developing blisters to her back. They said they were not sure why Resident #8 was left in that state and was very upset about the situation . In a confidential interview with facility employee W revealed there have been multiple residents developing new or worsened wounds. They said more recently, Resident #8 was left in a geri-chair for an extended period of time and from that developed blisters to their back. They said they were not sure why Resident #8 was left in that condition. An observation and interview on 8/3/2022 at 8:56 AM, visualization of Resident #8's back revealed, reddened areas on the right and left side of the spine mid-way down. Each contained open sores surrounded by skin fragments associated with the rupture of blisters. ADON P observed two open areas on the right side and obtained the following measurements 3.5cm x 3.5cm and 4.7cm x 5cm. one sore on the left measuring 6.0cm x 4.0cm. Wound beds are red/raw in appearance with small amount of clear drainage. A white paste-like substance was observed on each of the sores and spread throughout the reddened areas on her back. Resident #8 had nothing covering the open sores, with no barrier between her skin and the mattress. ADON P was not aware that the blisters had ruptured and did not have new treatment orders. ADON P stated the white paste like substance was zinc, a protective paste used to protect intact skin. Zinc used on non-intact skin could cause irritation and pain. In an interview on 8/4/2022 at 12:03 PM with ADON, stated she was notified of issues with Residents 8's back and was not provided with specifics. ADON revealed that there was not a process in place for notification of changes in a resident's skin. The ADON said neglect was knowingly not adequately caring for someone. The ADON said she felt staff had been neglectful regarding Resident #8 and her care that resulted in blisters which were worsened when staff were applying the wrong treatment once they had opened . In an interview on 08/04/22 at 1:00 PM with the Administrator revealed neglect was knowingly and willfully withholding care from a resident that they needed to sustain their wellbeing. The Administrator said he was not sure if there was neglect regarding Resident #8's care. In an interview on 08/24/22 at 9:50 AM with LVN M revealed the CNA's were completing rounds every two hours to reposition the residents and she as the nurse was expected to ensure it was completed. [NAME] said she checked off on Resident #8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] In an interview on 08/24/22 at 10:20 AM with the ADON revealed she was expected to reposition Resident #8 every two hours and check off that it was completed. In an interview on 08/24/22 at 11:45 AM with the DON revealed the CNA's will be responsible for repositioning or turning Resident #8 every two hours. The DON said that the MDS Nurses were monitoring Resident #8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The DON said the Nurses were responsible for ensuring the CNA's were repositioning/turning Resident #8. In an interview on 08/24/22 at 12:15 PM with the Administrator revealed the MDS nurses were completing daily audits on resident MAR's/TAR's ensuring documentation was completed. The Administrator said CNA's were rounding regularly and specified it as general rounds turning and repositioning residents every two hours. The Administrator said the Nurses are ensuring the CNA's are repositioning/turning residents every two hours. Review of Resident #8's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #8's August 2022 Completed Care Tasks by CNA's revealed they were checking off to: TURN EVERY 2 HOURS. Review of the facility's policy, revised April 2018, and titled Pressure Ulcers/Skin Breakdown - Clinical Protocol reflected: Section Monitoring, 3. The DON or designee will assess the condition of the residents' skin weekly and notify physician of any new or worsened conditions . 2. Review of Resident #7's face sheet, dated 08/06/22, reflected he was an [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's care plan, dated 01/18/22, reflected: as of 07/27/22 [Resident #7] has a surgical wound to [his] penis with approaches including [Resident #7] need[s] treatment as ordered by [his] physician, protect [his] area from further injury, monitor for changes in [his] skin status that may indicate worsening of [his] skin tear/laceration and notify the physician; as of 05/03/22 [Resident #7] has the potential for injury related to presence of indwelling catheter R/T urinary with [CONDITION(S)] with approaches including Secure catheter to thigh to prevent pulling on tubing. Review of Resident #7's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's quarterly MDS assessment, dated 06/10/22, reflected he had a BIMS score of 06, indicating severe cognitive impairment. Review of Resident #7's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview 8/3/2022 at 09:54 AM visualization of Resident #7's torso, revealed the absence of a dressing on the penis, and a catheter anchoring device on his left thigh without the catheter tubing. While the strap was on Resident #7's leg it was not being used to secure the catheter tubing in place. The foley catheter (tube inserted to drain urine from the bladder) drainage bag is hanging on the bed frame. The insertion point of the catheter is not the head of the penis. The anterior side of the penis was flesh colored, visualization of the underside of the penis revealed the absence of skin from the head to the base of the penis, the mucosal tissue appears moist, with a dark reddish/purple color. A defect is noted within the mucosal tissue with well-defined borders, the width of the catheter tubing that extends from the base of the head to the top of the bulb of the penis. Measured by ADON P as 7.50cx x 2.0cm x 0.10cm. ADON P stated this trauma was caused by the pulling of the foley catheter when the resident was moved, and the catheter was not secured to the resident. In an interview on 08/04/22 at 12:03 PM with the ADON revealed neglect was knowingly and not adequately caring for someone. The ADON said she felt staff were neglectful regarding Resident #7 and his catheter care by not ensuring he had his leg strap in place to keep his catheter from being pulled. The ADON said that she was not sure what happened to cause Resident #7 to have his catheter surgically implanted into his penis but said it could have been caused by staff not securing his catheter via the strap to his leg. In an interview on 08/04/22 at 1:00 PM with the Administrator revealed neglect was knowingly and willfully withholding care from a resident that they needed to sustain their wellbeing. The Administrator said he was not sure if there was neglect regarding Resident #7's care. In an interview via phone on 08/04/22 at 2:00 PM with the WCNP revealed it was really important for staff to anchor Resident #7's foley catheter so that it did not put pressure on his scar tissue. The WCNP said Resident #7 had had old trauma from years of being cathetorized and she had noticed herself some days where the catheter strap was not being used to anchor the catheter. The WCNP was unable to remember any specific days this occurred. The WCNP said she speculated the resulting surgical implantation for Resident #7 was due to trauma from tension of the catheter not being properly anchored by staff. The WCNP said although Resident #7 did not have feeling to the outside of his penis he did have feeling in his urethra and can feel when the catheter is pulled or caught from not being secured. In an interview on 8/4/2022 at 5:05 PM with ADON stated that residents with a catheter should have a leg strap to secure the tubing. The leg strap prevents the catheter from pulling causing trauma . Review of the facility's policy, revised September 2014, and titled Catheter Care, Urinary, reflected: .Steps in the Procedure #18 Secure catheter utilizing a leg band. Review of an in-service completed on 08/09/22 and titled Neglect/Assessment contained policies for Abuse/Neglect, Resident Exam and Assessment signed by multiple staff. Review of an in-service completed on 08/05/22 and titled Prevention and Screening- Clinical Protocol that included information about repositioning/turning residents every two hours signed by multiple staff.

Based on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services for one (Resident #7) of one residents observed for indwelling urinary catheters. The facility failed to ensure Resident #7 had a catheter strap to his leg after his catheter was dislodged on 06/29/22 resulting in him needing surgical intervention to implant it into his penis. This failure could place residents at risk for urethral tears, dislodging of the catheter, and urinary tract infections. Findings included: Review of Resident #7's face sheet, dated 08/06/22, reflected he was an [AGE] year-old male who originally admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's care plan, dated 01/18/22, reflected: as of 05/03/22 [Resident #7] has the potential for injury related to presence of indwelling catheter R/T urinary with [CONDITION(S)] with approaches including Secure catheter to thigh to prevent pulling on tubing. Review of Resident #7's August 2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's quarterly MDS assessment, dated 06/10/22, reflected he had a BIMS score of 06, indicating severe cognitive impairment. Review of Resident #7's July 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #7's August 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation and interview 8/3/2022 at 09:54 AM visualization of Resident #7's torso, revealed the absence of a dressing on the penis, catheter anchoring device on his left thigh without the catheter tubing. The foley catheter (tube inserted to drain urine from the bladder) drainage bag is hanging on the bed frame. The insertion point of the catheter is not the head of the penis. The anterior side of the penis was flesh colored, visualization of the underside of the penis revealed the absence of skin from the head to the base of the penis, the mucosal tissue appears moist, with a dark reddish/purple color. A defect is noted within the mucosal tissue with well-defined borders, the width of the catheter tubing that extends from the base of the head to the top of the bulb of the penis. Measured by ADON P as 7.50cx x 2.0cm x 0.10cm. ADON P stated this trauma was caused by the pulling of the foley catheter when the resident was moved, and the catheter was not secured to the resident. The injury was identified by blood on the bed, Resident #7 has no feeling or sensation below the waist. In an interview via phone on 08/04/22 at 2:00 PM with the WCNP revealed it was very important for staff to anchor Resident #7's foley catheter so it did not put pressure on the already existing scar tissue. The WCNP said there was not any health penile tissue to start with because of old trauma from years prior of being chronically catheterized. The WCNP said if the foley catheter was not anchored properly, the slightest bit of pull could cause more trauma. The WCNP said she had observed the foley catheter not anchored while she was in the facility observing wounds at times during the month of July but was not specific on which days this was. The WCNP said Resident #7 was originally sent to the ER after his foley catheter was pulled out of his penis which required it to be surgically placed instead. The WCNP said she speculated the resulting surgical implantation for Resident #7 was due to trauma from tension of the catheter not being properly anchored by staff. The WCNP said although Resident #7 did not have feeling to the outside of his penis he did have feeling in his urethra and can feel when the catheter is pulled or caught from not being secured. In an interview on 8/4/2022 at 5:05 PM with ADON stated that residents with a catheter should have a leg strap to secure the tubing. The leg strap prevents the catheter from pulling causing trauma. The ADON said she was not sure what happened to cause Resident #7 to have his catheter surgically implanted into his penis but said it could have been caused by staff not securing his catheter via the strap to his leg. In an interview on 08/04/22 at 1:00 PM with the Administrator said he was not familiar with Resident #7 or his care. The Administrator said he did not have a DON at the moment but that the ADON was responsible for ensuring staff had supplies for any treatments. Review of the facility's policy, revised September 2014, and titled Catheter Care, Urinary, reflected: .Steps in the Procedure #18 Secure catheter utilizing a leg band.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #21) of 11 residents reviewed for accidents and supervision. CNA A failed to ensure Resident #21 was provided with the necessary level of assistance when transferring the resident from the shower chair to her wheelchair. CNA A attempted to transfer Resident #21 alone with a gait belt instead of via the recommended mechanical sling lift, resulting in a fall from which Resident #21 sustained a fibula fracture. This failure resulted in one resident sustaining a fractured fibula, and put residents at risk of falls, injuries, or significant harm. Findings included: Review of Resident #21's Significant Change of Condition MDS Assessment, dated 04/28/19, revealed she was a [AGE] year-old female admitted to the facility on [DATE]. Resident #21's active [DIAGNOSES REDACTED]. She was totally dependent upon facility staff for all ADL's and required two person physical assistance for transfers. Review of Resident #21's Care Plan, dated 04/28/19 revealed the following: Problem: Resident requires extensive assist with bed mobility, locomotion on/off unit, personal hygiene, and bathing related to generalized weakness. Resident requires Hoyer lift after stroke due to weakness/[MEDICAL CONDITION] to one side. Review of Resident #21's Departmental Notes, dated 05/28/19 at 5:47 PM , revealed, This nurse (ADON C) was called into the shower room by (CNA D), resident (#21) noted to be sitting on the ground in front of wheelchair with gait belt on. CNA stated that she was assisting resident from shower chair to wheelchair when wheelchair moved out from under the resident on one side. CNA stated that she had locked the wheelchair but apparently one brake lock was not pushed all the way down and lock came undone. CNA lowered resident to the floor at that time. Upon assessment, resident was noted to have bleeding coming from the buttocks. Resident was assisted into wheelchair and then into bed by staff. Resident noted to have hematomas to area between coccyx and rectum. Pressure applied to bleeding areas until bleeding subsided. Resident complained of left knee and right ankle pain once assisted back to bed. (Physician) notified of fall, new order for STAT (immediate) x-ray to left knee and right ankle to rule out injuries. Daughter notified of fall and x-ray orders. Resident resting quietly in bed at this time. Review of Witness Statement made by CNA D dated 05/28/19 reflected, I was transferring her (Resident #21) back to her wheelchair from the shower chair. I had my gait belt on her and I had her hold the bar that is on the wall like we had done before to get her in the shower chair. Our first attempt failed in getting her in her chair (it) failed because we didn't have a good hold on the bar so we sat back down in the shower chair and tried again. This time when we stood up I tried drying her bottom off to pull her pants up she said that she was 'going down' so I pulled her wheelchair as close as I could get it at the time and was trying to lock her right brake all the way, but she started buckling her knees. I tried positioning myself to where she could sit in her chair without me being in the chair with her while pulling the chair even closer. We were slowly sitting down in the chair as best as possible, but the right side of the chair kept moving back as we were trying to sit causing her to have only one side of her bottom on the chair. I tried lifting her up and have her straighten her knees so I can push the chair underneath her better on the right side but she have (sic) very much strength left in her legs to do it. So instead of trying that again I made the decision to lift her up a little ways and have her rest against my leg and my body weight and I unlocked the wheels and we slowly sat on the floor and called for help. As help was on the way I asked her if she was in any pain anywhere and she said no. I asked if her legs or her bottom was hurting and again she said no. By that time my partner (CNA E) came in, went to get the nurse and med aide while I stayed with (Resident #21). I questioned her again about if she was in pain anywhere and she once again declined but had asked if there was any way I could straighten her legs out. I did my best to do so and then (ADON C) came in and took her vitals and assessed her as much as they could. Then all four of us tried lifting her up but as we lifted her I noticed as well that she was bleeding from her bottom so we set her back down put a towel in her chair and then lifted her again and got her into her chair successfully after adjusting Resident #21 back a couple of times. Then (ADON C) took her to her room with (CNA E) and had transferred her to her bed to assess her even more and focused more on her rectal area which is where the blood was coming from. About 5 minutes after I asked (Resident #21) again if she was hurting anywhere and she said yes and told me her right ankle was hurting as well as her left knee which I then noticed was skinned. I immediately told (ADON C) what (Resident #21) had said. She did not hit her head. The only thing that touched the floor was her bare bottom and her legs. Review of Resident #21's X-Ray, dated 05/28/19, reflected: Technique: Four images of the right ankle as well as tibia and fibula were obtained. Findings: Comminuted fractures proximal (towards the knee) fibular (smaller lower leg bone located on the outside of the leg) shaft. According to the American Academy of Orthopaedic Surgeons a comminuted fracture is when the bone shatters into three or more pieces. (accessed from https://orthoinfo.aaos.org/en/diseases--conditions/fractures-broken-bones on 06/26/19). In an interview with the MDS Coordinator on 06/20/19 at 3:42 PM revealed that the closet care plans were created for the aides on the floor to know the transfer status, code status, and toileting status. Review of Resident #21's Closet Care Plan undated revealed Resident #21 was identified as requiring a Hoyer lift for transfers and the assistance of two people for bathing. Prior to the fall, there was a list of transfer options that had not been selected to identify the residents transfer needs. ADON B identified the care plan as the one that was in place at the time of the incident, but stated that she had circled Hoyer after the fall in the shower room. In an interview on 06/20/19 at 2:10 PM CNA D stated on the day of the incident involving Resident #21 she had pulled the call light for assistance in the shower. She stated her partner was on her break and Resident #21 was getting impatient waiting to be transferred. CNA D stated that she had pressed the call light in the shower room, and was waiting for some time but no one came. CNA D stated she decided to transfer the resident by herself via the gait belt, because the resident was getting impatient and complaining of pain from sitting. CNA D stated that Resident #21's Closet Care Plan identified the resident as being a two-person transfer. CNA D stated she was not aware that Resident #21 required a Hoyer lift for transfers until after the incident. CNA D stated that she was in-serviced on proper transfers and was suspended for two days following the incident. In an interview on 06/20/19 at 09:12 AM with Resident #21 said that no one picked her up to transfer her, because no one would be able to do it even if they tried. Resident stated that she had been using a Hoyer Lift to get out of bed. The resident stated that she was not planning to return to the facility. In an interview on 06/20/19 at 3:42 PM with the MDS Coordinator revealed that Resident #21 required a Hoyer lift for transfers following [MEDICAL CONDITION], and that's what triggered the significant change assessment which was completed on 04/28/19. The MDS Coordinator stated that she works along with therapy to create the transfer status. MDS Coordinator stated that MDS Coordiantors updated the care plan, and the ADON's and herself were responsible for the closet care plans for the aides. The MDS Coordiantor did not know why the care plan was not changed following her change in transfer status. In an interview on 06/20/19 at 3:53 PM the Rehab Director stated that Resident #21 was in fact a Hoyer transfer after [MEDICAL CONDITION] but on 05/03/19 she had made progress and was no longer requiring the Hoyer lift to transfer and required 2 person assistance. The Rehab Director stated that she had open communication with the nurses on the floor and the MDS Coordinator and was not aware why the care plan did not change to the required 2-person assist for Resident #21. In an interview on 06/20/19 at 4:29 PM with ADON C revealed she was working the day of the incident involving Resident #21, and was called into the shower room to provide assistance. ADON C stated when she did her initial assessment the resident stated that she was not in any pain. ADON C stated when they got the resident up got there was blood underneath her and she had skin tears near her coccyx and rectum. ADON C stated Resident #21 then started complaining of her knee hurting, and an order for [REDACTED]. She stated the x-ray showed the fractured fibula. ADON C stated that she believed the resident was a two person transfer and knows that after [MEDICAL CONDITION] she required a Hoyer lift for transfers. ADON stated that the resident's closet care plan should reflect the same information as the comprehensive care plan. In an interview on 06/20/19 at 5:10 PM the Administrator revealed that his expectation was for all of the nursing staff to go by the care plan because it's the plan of care. The Administrator stated that his re-training on safe transfers was still ongoing, and he did not have a date in mind for when he thought the training would be done. Record Review of Confidential Employee Corrective Action Form dated 05/29/19 revealed employee CNA D was given a written warning for a violation of their Transfer Policy and Performance Issue. Conduct that was observed and/or substantiated: transferred resident with one assist, resident is 2 person assists. Suspension pending investigation. Review of the measures taken by the facility to correct the non-compliance prior to entry on 06/20/19 revealed the following: Record Review of Gait Belt Transfer Proficiency for employee CNA D, dated 05/30/19 revealed that she passed the checklist, by demonstration. Record Review of the facility's Employee Performance Improvement Plan for CNA D, dated 05/30/19, revealed that there was a performance issue identified. The plan identified that CNA D did not follow a resident's plan of care for transfers, and transferred a resident alone when the care plan called for two person assist (Resident #21's Care Plan reflected the resident to be a Hoyer transfer). - Goals are for the resident to follow the plan of care with all resident transfers to help promote resident safety. The time frame for the action plan set in place is 90 days. If CNA D does not follow the plan termination will take place. An observation on 06/20/19 at 05:50 PM CNA D revealed the aide conducted a two-person Hoyer transfer on Resident #27. The aides were interacting with the resident, strapped the resident, and safely transferred the resident to bed. No concerns were noted. Review of facility policy, Safe Lifting and Movement of Residents dated (MONTH) (YEAR) revealed, nursing staff, in conjunction with the rehabilitation staff, shall assess individual's residents needs for transfer assistance on an ongoing basis. Manual lifting of residents shall be eliminated when feasible. Staff will document resident transferring and lifting needs in the care plan. Review of facility policy, Lifting Machine, Using a Mechanical dated (MONTH) (YEAR), reflected the following: at least two nursing assistants are needed to safely move a resident with a mechanical lift: lifting a resident from the floor, transferring resident from bed to chair, lateral transfer, Lifting limbs, toileting or bathing, repositioning. Steps in the Procedure: before using a lifting device, assess the residents current condition including: Physical (Can the resident assist with transfer, is the residents weight and medical condition appropriate for the use of a lift), Cognitive/Emotional (Can the resident understand and follow instructions, does the resident express fear or appear anxious about the use of a lift, is the resident agitated, resistant, or combative.). Measure the resident for proper sling size and purpose, according to manufacturer's instructions. Select the sling bar that is appropriate for the resident's size and the task.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for three (Residents #1, #2, and #3) of five residents reviewed for falls. 1. CNA A failed to ensure Resident #1 was transferred by two staff using a gait-belt, which resulted in the resident falling and fracturing her left lower extremity on 01/19/17. 2. CNA B failed to ensure Resident #2 was transferred by two staff using a gait-belt, which resulted in the resident falling. 3. CNA C failed to ensure Resident #3 was transferred using a gait-belt to promote a safe transfer and prevent an accident. These failures affected two residents and could affect the 28 residents who resided on Hall 200 where CNA B worked and the 30 residents on Hall 300 where CNA C worked, by placing them at risk for falls, physical harm, pain, and/or fractures. Findings included: 1. Resident #1's MDS assessment, dated 01/20/17, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had severe cognitive impairment, required the assistance of two persons for transfers, and had one fall at the facility. Resident #1's care plan, dated 01/13/17, reflected the resident was at risk for falls and required assistance with transfers. The care planned interventions included, provide level of support to complete transferring needs every shift. Resident #1's nurse's notes, dated 01/20/17, reflected the resident was transferred from the wheelchair to the bed by CNA A on 01/19/17 and fell . The resident complained of left leg pain and was sent to the emergency room . The resident returned to the facility with a [DIAGNOSES REDACTED]. Resident #1's incident report, dated 01/19/17, reflected the resident fell during a transfer by CNA A to the bed from the wheelchair on 01/19/17 at 8:45 p.m. The resident was sent to the emergency room . Resident #1's Radiology report, dated 01/19/17, reflected the resident had an x-ray of her left ankle which revealed a non-displaced fracture involving the distal tibia (bone in the lower leg) and fibular diaphysis with mild impaction of the distal tibia. Resident #1's Provider Investigation Report, dated 01/26/17, reflected CNA A transferred the resident from her wheelchair to the bed, but did not follow lifting/transfer protocols. During the transfer, CNA A lost her balance and she and the resident fell to the floor. The resident sustained [REDACTED]. CNA A's witness statement, dated 01/20/17, reflected she could not find a gait belt to transfer the resident and her partner said she could do the transfer by herself. CNA A was terminated from employment. The facility completed an in-service, not dated, which stated to utilize a gait belt when transferring residents. An observation of Resident #1 on 02/02/17 at 9:10 a.m. revealed she was sitting in her wheelchair, and she had a hard cast on her left lower leg. An interview with the resident at the time of the observation revealed she fractured her leg when a CNA got dizzy while transferring her. She stated the CNA did not know how to transfer her, and another staff that was there at the time of the transfer told the CNA that she could transfer the resident by herself. An interview was attempted with CNA A on 02/02/17 at 10:40 a.m., but CNA A did not return the phone call of the surveyor. An interview with CNA D on 02/02/17 at 2:50 p.m. revealed she worked with CNA A on 01/19/17. She stated CNA A asked her how to transfer Resident #1, and she told CNA A Resident #1 required two staff and a gait-belt to transfer. CNA D stated she was in another resident's room when she was told by LVN E that Resident #1 had fallen during a transfer. CNA D stated she went to Resident #1's room, and CNA A told her she dropped the resident. CNA A told her she did not use a gait-belt to transfer Resident #1. CNA D stated CNA A did not ask her to help transfer Resident #1. An interview with LVN E on 02/02/17 at 3:30 p.m. revealed she worked with CNA A on 01/19/17. She reported CNA A came and told her she dropped Resident #1 and that she did not use a gait-belt to transfer the resident. LVN E stated she assessed the resident then sent the resident to the hospital emergency room . She stated she did not know why CNA A tried to transfer the resident without assistance because it had been made very clear to staff the resident required two staff to transfer. 2. Resident #2's MDS assessment, dated 11/11/16, reflected the resident was a [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was cognitively intact and required the assistance of two persons for transfers. The resident had not had any falls. Resident #2's care plan, dated 10/01/14, reflected the resident was at risk for falls and required assistance with transfers. The care planned interventions included, provide level of support to complete transferring needs every shift. Resident #2's nurse's notes, dated 11/20/16, reflected the resident slid to the floor during a transfer with CNA B. The resident did not sustain an injury. Resident #2's incident report, dated 11/20/16, reflected the resident slid to the floor during a transfer by CNA B on 11/20/16 at 10:30 a.m. The resident required three staff to assist her off of the floor and into the recliner. CNA B's witness statement, not dated, reflected she was transferring the resident from the wheelchair to the chair when the resident's feet slipped out from under her and she slid down the chair to the floor. An interview with Resident #2 on 02/02/17 at 1:30 p.m. revealed she had slid to the floor during a transfer on 11/20/16. She stated one staff member was helping her, and the staff member did not use a gait-belt. She stated she did not get hurt as a result of falling. She stated usually only one staff member transferred her, and staff usually did not use a gait-belt to transfer her. An interview with CNA B on 02/02/17 at 1:45 p.m. revealed during a transfer on 11/20/16, Resident #2 stood up and slid down to the floor. CNA B stated she was using a gait belt, and she tried to transfer the resident alone because the resident was able to hold onto her walker. CNA B then said maybe she was wrong and thought maybe CNA G had helped her to transfer the resident during the fall. She reported she thought two to three staff members were required to transfer the resident. An interview with CNA G on 02/02/17 at 1:50 p.m. revealed she did not assist CNA B to transfer Resident #2, but she did help to pick Resident #2 off of the floor after she fell . An interview with the Physical Therapy Director on 02/02/17 at 3:00 p.m. revealed Resident #2 required two persons to transfer. 3. Resident #3's MDS assessment, dated 11/02/16, reflected the resident was an [AGE] year-old female, who was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident had moderately impaired cognitive skills, required the assistance of two persons for transfers, and had not had any falls. Resident #3's care plan, dated 08/02/16, reflected the resident required assistance with transfers and was at risk for falls. The care plan reflected the resident fell on [DATE]. The care planned interventions included, provide two person level of support to complete transferring needs every shift. An observation on 02/02/17 at 11:50 a.m. revealed CNA C assisted Resident #3 to sit on the side of the bed. She then put shoes on the resident's feet. CNA C had a gait-belt sticking out of her uniform pocket. CNA C had the resident scoot to the edge of the bed and assisted her to stand. CNA C held onto the resident's clothes while she turned to sit the resident in her wheelchair. CNA C did not use a gait-belt to transfer the resident, and CNA C did not have another staff to assist her per the resident's documented care plan. An interview with CNA C on 02/02/17 at 11:55 a.m. revealed she did not use a gait-belt to transfer Resident #3 because the resident was pretty strong. She stated the gait-belt was used for residents who required more assistance with transfers like Resident #1. An interview with the Physical Therapy Director on 02/02/17 at 3:00 p.m. revealed Resident #3 required two persons to transfer when she was first admitted to the facility, but she only required one person to transfer currently. 4. An interview with ADON F on 02/02/17 at 12:00 p.m. revealed gait-belts were to be used for all transfers unless the resident could ambulate independently. An interview with the DON on 02/02/17 at 12:20 p.m. revealed she spoke to CNA C and was aware she did not use the gait-belt during the transfer with Resident #3 and that she should have. The DON stated corrective action was taken with CNA C because she violated the transfer policy. An interview with the Physical Therapy Director on 02/02/17 at 3:00 p.m. revealed staff was supposed to use a gait-belt for every transfer. 5. The facility's current, undated Transfer of Patient policy and procedure reflected the following: .Equipment .Gait belt .Help resident to sit on edge of the bed with legs an(d) feet hanging over the edge Stand in front of the resident with a firm grasp on gait belt that has been secured around resident waist Help resident stand One Person Pivot Transfer .Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot Assist resident to sit at bedside with feet on the floor. The resident's knees should be separated to provide a wide base of support Apply gait belt snugly around waist Stand in front of resident. Keep your feet apart, knees bent, and back straight Place one hand under each side of the gait belt using and (sic, an) underhand grip Two Person Pivot Transfer .Staff will use gait belt to assist in getting resident to stand and guiding resident to pivot Assist resident to sit at bedside with feet on the floor. The resident's knees should be separated to provide a wide base of support Apply gait belt snugly around waist Stand in front of the resident. Each staff member places one hand under the front of the belt and one hand under the back of the belt, using an underhand grip .The staff member closes to the chair stands in a position so that he or she can pivot and move away, allowing the resident unobstructed access to the chair .On the count of three both nursing assistants will move resident at the same time. Coordination of the movement is important Instruct the resident on the count of three to lean forward and push up from the bed with his/her hands while you assist bringing the resident's weight forward with the belt. Support the resident's knees and feet by placing your knees and feet firmly against them 6. The Facility Census, dated 02/02/17, reflected CNA B provided transfer assistance to 28 residents on the 200 hall and CNA C provided transfer assistance to 30 residents on the 300 hall.