Every finding on record at Focused Care at Crane

Based on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 3 of 4 quarterly meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended quarterly QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed. Findings included: Interview during the Entrance Conference on 6/24/25 at 9:56 a.m. the Administrator identified the Medical Director. The Administrator stated the QA meetings were held monthly with all department heads, a corporate representative, and a representative from the hospital district that owned the facility. The Administrator stated the Medical Director attended occasionally. When asked to specify what occasionally meant, the Administrator stated the Medical Director only attended the QA meetings one time in the last year. The Administrator said the Medical Director was in the building monthly to see residents and his Nurse Practitioner was in the building two times a month. The Administrator stated the facility constantly remained in communication with them. Review of the Quality Assurance Performance Improvement Attendance Sign-In forms revealed: Quarter 1: 6 (June)/2024: The Medical Director attended. Quarter 2: 7/9/24, 8/13/24 - The Medical Director did not attend Quarter 3: 9/10/24, 10/8/24, 11/12/24 - The Medical Director did not attend. (undated 12/??/.24 - staff were the staff that were there in 2024), 1/14/24 (error), 2/11/25 - The Medical Director did not attend. Quarter 4: 3/11/25, 4/8/25, 5/13/25- The Medical Director did not attend. 6/1/25 - The Medical Director did not attend. In an interview on 6/26/25 at 10:48 p.m., the Regional RN Consultant stated the facility policy on Medical Director attendance was that every Department Head should participate monthly and the Medical Director should attend quarterly. The RN Consultant stated she was unaware of when the last time the Medical Director attended the QA meeting at the facility. When informed he attended one QA Meeting in the last 12 months, the RN Consultant stated she did not know why the Medical Director only attended one time because he should have at least attended over the phone. Review of the facility's policy and procedure on Quality Assurance and Performance Improvement, effective 3/1/17, revealed: This facility shall develop, implement, and maintain and ongoing facility wide QAPI Plan designed to monitor and evaluate the quality and safety of resident care, pursue methods to improve care, quality, and resolve identified problems. Authority: The owner and/or governing board (body) of our facility shall be ultimately responsible for the QAPI program. The Administrator is responsible for assuring that this facility's QAPI Program complies with federal, state, and local regulatory agency requirements.

Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 7 residents (Resident #25, #32 and #37) reviewed for quality of care in that: 1. The facility failed to assess and care plan Resident #25 for safe vaping, 2. The facility failed to keep Resident #25's vape secure when it was not a supervised smoking time 3. CNA E and CNA D incorrectly transferred Resident #32 the shower chair to the bed by incorrectly applying the gait belt too loosely and hooking under Resident #32's arms. 3.CNA A and CNA B incorrectly transferred #37 from her wheelchair to the bed by grabbing her from the back of her pants and her under arms. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life. Findings included: RESIDENT #25 Review of Resident #25's admission Record dated [DATE], revealed he was an [AGE] year-old male admitted to the facility on [DATE] and a re-admission dated of [DATE], with diagnoses including unspecified dementia without behavioral disorder. Review of Resident #25's admission MDS assessment, dated [DATE], revealed: He had a mental status score of 7 of 15 (indicating his cognition was severely impaired) He was not identified as a current tobacco user. Review of his care plan revealed there was no care plan for his nicotine use. Review of Resident #25's Baseline Care Plan dated [DATE] revealed Does the resident smoke? No Review of Resident #25's assessments revealed no smoking assessments. Review of Resident #25's Nurse's Notes dated [DATE] at 6:03 p.m. revealed: Note Text: Resident attempted to elope from facility thru the front door. Nurse and DON stopped resident at door. Resident stated that he was going to the head shop to go get a vape. Resident was educated that he cannot leave facility on his own. Resident verbalized understanding. A wander guard was placed on resident to monitor elopement risk. Interview and observation on [DATE] at 2:43 PM revealed Resident #25 had several vapes on the bedside table, smoking times posted. Resident #25 said he went outside for smoking times but did not on [DATE] because he hurt too much. Interview and observation on [DATE] at 10:37 AM Resident #25 stated he was not vaping in the building. Resident #25 said he had to take vape from another resident and forgot to turn it into the lady. The vape was in same place as [DATE]. Interview on [DATE] at 11:23 AM the DON and Corporate RN stated smoking was assessed on admission and quarterly The Corporate RN said people who vaped were also assessed. The DON said she talked Resident #25 and he had two vapes on the bedside table which she took away. The DON checked Resident #25's electronic record and stated he had not assessments and it did not look like he had a care plan for vaping. She said she did not know why he did not. The DON said it should pop up under the initial care plan for nursing and the MDS nurse was responsible for completing the care plan after that. The DON stated no one has caught him vaping in the building. The DON stated Resident #25 was usually up and about and compliant with the smoking policy. Resident #32 Review of Resident #32's admission Record, dated[DATE], revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included dementia and gait abnormalities. Review of Resident #32's Annual MDS Assessment, dated [DATE], revealed She had a mental status score of 5 of 15 (indicating severe cognitive impairment) She was totally dependent on staff for transfers. Review of Resident #32's Care Plan, revised [DATE], revealed: Resident #32 had an ADL Self-care performance deficit related to disease process, dementia. The goal was Resident #32 would maintain her current level of function through the review date. Identified interventions included: Transfer: The resident is dependent on staff for assistance with transferring. Observation on [DATE] at 1:46 PM Resident #32 gave permission to watch the transfer. CNA E put the gait belt on Resident #32. CNA E and CNA D stood on either side of Resident #32, hooked their arms under her arms and grabbed the back of the gait belt. While lifting Resident #32, the gait belt slid up Resident #32's chest, Resident #32 did not straighten her legs so all of her weight was hanging by her arms. The aides put Resident #32 in the low bed and removed the gait belt. At that time CNA D said aides were trained on transfers but she did not know why they put the gait belt on when Resident #32 had pants on but Resident #32 being in a shower chair threw her off. CNA E stated Resident #32 could straighten her legs but frequently did not so the majority of the time Resident #32 was not weight bearing because she would not straighten her legs. CNA E said she was pretty sure the charge nurses were aware of that. CNA D said Resident #32 got skin tears easily. Both aides said they would not do anything differently and had check-offs done pretty frequently and that the DON had checked them off for two-person gait-belt transfer. Neither aide was aware of an increased risk of injury to Resident #32 to hooking their arms under her arms since she was non-weight bearing. Interview on [DATE] at 11:08 AM the DOR stated a 2-person transfer from the wheelchair would be 1 person put the gait belt on while the other steadied the resident. The DOR said one person should stand in front of the resident while the other guides from the back. The DOR stated after the wheelchair was locked the resident should be cued, stood and then pivoted to sit. The DOR stated if the gait belt slid up it was not a safe transfer. The DOR said if the resident's feet did not touch ground it was not a safe transfer if the resident's feet were not touching ground there was a potential for falls. The DOR stated the potential outcome for the resident was a fall. The DOR stated the gait belt could cause skin tears, the staff could get injured if someone got off balance. The DOR stated potential injuries to hooking under a resident's arms were shoulder injury from stretching and instability which could cause the resident pain. Interview on [DATE] at 11:16 AM the DON and Regional RN stated a safe 2-person gait belt transfer looked like each staff took a side of the resident, grab back and front of the gait belt, come up at the same time and move the resident from one surface to the other. The DON said staff should not grab under resident's arms. The Corporate RN stated non-weight bearing resident was not a safe two-person transfer. The DON stated staff must not have been checking the Kardex (where the resident's ADL status is kept in the electronic monitoring system). The DON looked up Resident #32's status and read the Kardex documented Resident #32 was dependent on staff for transfer so it had to be updated. The Corporate RN asked about the care plan. The DON said it would be easier for staff and safer for resident to be a lift resident. Interview on [DATE] at 12:00 PM the Administrator and [NAME] President of Regional were informed there was an issue with safe two-person transfers for Resident #32. Neither had questions. RESIDENT #37 Record review of Resident #37's admission record dated [DATE] indicated she was admitted to the facility on [DATE] with diagnoses of Alzheimer's disease and muscle weakness. She was [AGE] years of age. Record review of Resident #37's MDS dated [DATE] indicated in part: For cognitive Skills for Daily Decision Making, the resident's was severely impaired. Transfers - (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) the resident required extensive assistance;resident was involved in the activity, staff provide weight-bearing support, and two+ persons were required for physical assistance. Record review of Resident #37's care plan dated [DATE] indicated in part: Focus: I have an ADL self-care performance deficit r/t disease processes Alzheimer's. Goal: The resident will maintain current level of function through the review date. Interventions: Transfer: The resident requires limited to extensive staff assistance with transferring. During an observation and interview on [DATE] at 12:20 PM in the secure unit, CNA A and CNA B transferred Resident #37 from her wheelchair to her bed. Both CNAs took the resident from underneath her armpits and by the back of her pants. The resident was unable to assist with the transfer and the staff had to manually perform the transfer for her. CNA A said she was not sure what the transfer status was for Resident #37, but that they usually did two person transfers on all the residents on the secure unit. CNA B said she believed the transfer status was listed on their POC (plan of care) tablet they charted on but was not sure. During an observation and interview on [DATE] at 03:06 PM, CNAs A and B were seen wearing gait belts around their waists. The CNAs said the gait belts had recently been brought to them so they could use them to transfer residents. The CNAs were asked about the transfer they had performed on Resident #37. The CNAs acknowledged that they should have used a gait belt for Resident #37 but that at the time they did not have the gait belts. The CNAs said if they transferred the residents from under their arms and the back of their pants it could lead to injuries. CNAs said they documented on their POC tablet and that was where the transfer status was listed. During an observation on [DATE] at 03:10 PM, the CNAs POC tablet indicated for Resident #37 transfer self-performance - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position. Total dependence - full staff performance. During an interview on [DATE] at 09:40 AM, the DOR (Director of Rehab) was made aware of the transfers made by the CNAs. The DOR said it was expected for the staff to use a gait belt for all transfers for safety. The DOR said taking the resident's from under their arms could lead to injuries. The DOR said if the resident's care plan indicated to use a mechanical lift, then staff should have used the lift. The DOR said she would do in-services with staff on safety transfers. During an interview on [DATE] at 10:40 AM, the Administrator was made aware of the transfers performed by the CNAs by taking the residents from their armpits and the back of their pants. The Administrator said transferring the residents like that could lead to injuries. The Administrator said the staff should have used a gait belt or the mechanical lift to transfer the residents. The Administrator said they would conduct training and in-services regarding the use of gait belts and the mechanical lift. The Administrator said she believed the DON conducted monitoring rounds of the facility and observed how staff performed tasks. During an interview on [DATE] at 10:45 AM, the DON said the staff was expected to use a gait belt for transferring residents. The DON said the staff were not supposed to transfer the residents by taking them from their underarms and clothing. The DON said if the staff transferred the resident from under their arms, that could lead to injuries. The DON said they would be conducting more training and getting together with the DOR to work together and conduct some training with the staff. The DON said they planned on conducting more observations of staff to make sure staff were following the correct steps. Review of the facility's policy and procedure on Smoking, effective [DATE], revealed: It is the policy to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. Procedure: Incendiary devices will be stored by facility staff. Resident will not be allowed to possess any lighters, cigarettes, or other smoking materials. All vaping material will also be secured. Electronic cigarettes will follow the same rules as tobacco. IDT will develop an individualized plan for safe storage, use of smoking materials assistance and required supervision for residents who smoke. This is documented on the Resident Smoking Assessment, the president's Plan of Care, and discussed with the resident and Responsible Party at resident care conference meetings. Record review of the facility's policy titled Safe lifting and movement of residents and dated [DATE] indicated in part: In order to protect the safety and well-being of staff and residents and to promote quality care this facility uses appropriate techniques and devices to lift and move residents. Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents. Manual lifting of residents shall be eliminated when feasible. Nursing staff in conjunction with the rehabilitation staff, shall assess individual residents needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include: Resident mobility, Weight-bearing ability. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurateacquiring, receiving, labeling, dispensing, safe and secure storage of medications for 2 of 2 medication carts(200 hall and 300 hall) checked for storage of medications. - The 200 hall medication cart had a bottle of milk of magnesia with dried drippings on the lid of the bottle. - The 300 hall medication cart had an empty bottle of Pro Stat liquid collagen with dried drippings on the side of the bottle - The 300 hall medication cart had two open undated insulin pens for Resident #7 and Resident #14 These failures could affect residents that received medications at the facility by placing them at risk of cross contamination and receiving ineffective insulin therapy. Finding included: Resident # 7 Review of Resident #7's face sheet dated [DATE] revealed a [AGE] year-old female with an original admission date of [DATE] and a readmission date of [DATE]. Review of Resident #7's history and physical dated [DATE] revealed Type 2 diabetes mellitus with hyperglycemia. Review of Resident #7's quarterly MDS assessment dated [DATE] revealed a BIMS score of 05, indicating severe cognitive impairment. Review of Resident #7's Care Plan dated [DATE] revealed resident has Diabetes Mellitus and received oral medications and insulin to control blood glucose levels. Record review of Resident #7's physician orders reflected the following order: Tresiba FlexTouch Subcutaneous Solution Pen-injector 200 UNIT/ML (Insulin Degludec) Inject 40 unit subcutaneously in the morning for Diabetes Mellitus. Resident # 14 Review of Resident #14's admission record dated [DATE] revealed a [AGE] year-old female with an admission date of [DATE]. Review of Resident #14's history and physical dated [DATE] revealed Type 2 diabetes mellitus with unspecified complication and diabetic polyneuropathy. Review of Resident #14's admission MDS assessment dated [DATE] revealed a BIMS score of 07, indicating severe cognitive impairment. Review of Resident #14's Care Plan dated [DATE] revealed resident has Diabetes Mellitus and received insulin to control blood glucose levels. Record review of Resident #14's physician orders reflected the following order: Basaglar KwikPen 100 Unit/ml solution pen-injector 200 UNIT/ML (Insulin glargine) Inject 27 units subcutaneously once a day. An observation on [DATE] at 10:38 am revealed LVN G's medication cart had an empty bottle of pro stat liquid collagen with dried drippings running down the side of the bottle. An observation on [DATE] at 10:40 am revealed two opened, undated insulin injection pens for two residents (Residents #7 and Resident#14) in LVN G's medication cart. An observation on 06 25/2025 at 11:17 am revealed a bottle of milk of magnesia with dried drippings around bottle cap in LVN F's medication cart. An interview with the DON on [DATE] at 08:40 AM revealed that all insulin pens were dated upon opening. The DON stated that insulin should have been dated upon opening because insulin expired after 28 days putting residents at risk for receiving expired insulin, which could have led residents to receiving ineffective insulin treatment. The DON stated that medication bottles needed to be wiped down after use to prevent bottles from being stored with dried drippings. The DON stated that it was important for bottles to be stored clean to prevent cross contamination. The DON stated that nurses and med aides were responsible for ensuring bottles were clean when being stored. The DON stated that the last in-service done regarding medication storage was done last Friday. An interview with LVN F on [DATE] at 11:27 pm revealed that insulin pens should be dated as soon as they were opened for first use. LVN F stated the nurses were responsible to make sure that all pens were dated. A negative outcome for the resident would be using an old pen that was out of the range of the 28 days and ineffective insulin therapy. LVN F stated that all medication bottles were supposed to be cleaned prior to storing them back into the medication cart to prevent cross contamination. An interview with LVN G on [DATE] at 2:47 pm revealed that the insulin pens were dated as soon as they were opened. LVN G stated that all nurses were responsible to make sure all dates were printed clearly on the insulin pen. A negative outcome of using an undated pen would be not knowing how long ago it was opened thus leading to medication being less effective. LVN G stated that medication bottles were to be cleaned after use and before being stored in medication cart to prevent cross contamination. Review of facility's policy titled Storage of Medications revised [DATE] revealed, . the nurse shall place a date opened sticker on the medication and record the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days from opening unless the manufacturer recommends another date or regulations/ guidelines require different dating .The nurse will check the expiration date of each medication before administering it, no expired medication will be administered to a resident.

Based on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Residents #25) reviewed for care plans in that: Resident #25 did not have a Care Plan addressing his vape use/smoking. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. The findings included the following: Review of Resident #25's admission Record dated 6/26/25, revealed he was an [AGE] year-old male admitted to the facility on [DATE] and a re-admission dated of 5/7/25, with diagnoses including unspecified dementia without behavioral disorder. Review of Resident #25's admission MDS assessment, dated 5/10/25, revealed: He had a mental status score of 7 of 15 (indicating his cognition was severely impaired) He was not identified as a current tobacco user. Review of his care plan revealed there was no care plan for his nicotine use. Review of Resident #25's Baseline Care Plan dated 5/7/25 revealed Does the resident smoke? No Review of Resident #25's assessments revealed no smoking assessments. Review of Resident #25's Nurse's Notes dated 5/27/2025 at 6:03 p.m. revealed: Note Text: Resident attempted to elope from facility thru the front door. Nurse and DON stopped resident at door. Resident stated that he was going to the head shop to go get a vape. Resident was educated that he cannot leave facility on his own. Resident verbalized understanding. A wander guard was placed on resident to monitor elopement risk. Interview and observation on 06/24/25 at 2:43 PM revealed Resident #25 had several vapes on the bedside table, smoking times posted. Resident #25 said he went outside for smoking times but did not on 6/24/25 because he hurt too much. Interview and observation on 06/26/25 at 10:37 AM, Resident #25 stated he was not vaping in the building. Resident #25 said he had to take a vape from another resident and forgot to turn it into the lady. The vape was in same place as 6/24/25. In an interview on 06/26/25 11:23 AM, the DON and Corporate RN stated smoking was assessed on admission and quarterly. The Corporate RN said people who vaped were also assessed. The DON said she talked to Resident #25 and assessed him for pain, and he had two vapes on the bedside table which she took away. The DON said the Administrator was with her where she took them away. The DON checked Resident #25's electronic record and stated he had no assessments and it did not look like he had a care plan for vaping. She said she did not know why he did not. The DON said it should pop up under the initial care plan for nursing and the MDS nurse was responsible for completing the care plan after that. Review of the facility's policy and procedure on Comprehensive Care Plan, revised 4/25/21, revealed: Every resident will have an individualized interdisciplinary plan of care in place. A baseline plan of care to meet the resident's immediate needs shall be developed for each resident within forty-eight (48) hours of Admission. The Interdisciplinary Team will continue to develop the place in conjunction with the Resident Assessment Instrument completing and conducting Comprehensive Care Plan Meeting and Reviews by day 21 after Admission. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process. To assure that the resident's immediate care needs are met and maintained, the baseline care plan will be developed with forty-eight hours of the residents' Admission. It will be utilized until the Comprehensive Care Plan is developed. The Comprehensive Care Plan is developed within 21 days of Admission. Care Plan Meeting and Care Plan Summary will be completed by the IDT after each Care Plan Review. The resident and their representative will be provided a summary at their request of the baseline care plan that includes but not limited to: Any services and treatment to be administered by the community and personnel acting on the community. Review of the facility's policy and procedure on Smoking, effective 3/1/17, revealed: It is the policy to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them, and protecting the non-smoking residents. IDT will develop an individualized plan for safe storage, use of smoking materials assistance and required supervision for residents who smoke. This is documented on the Resident Smoking Assessment, the residents' Plan of Care, and discussed with the resident and Responsible Party at resident care conference meetings.

Based on interviews and record reviews, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 3 residents (Resident #34) reviewed for nutrition. The facility failed to provide care and services to maintain acceptable parameters of nutritional status for Resident #34. This failure could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life. The findings included: Review of Resident #34's admission Record, dated 6/25/25, revealed he was admitted to the facility on [DATE] with diagnoses including partial intestinal obstruction, unspecified cause, unspecified dementia, fecal impaction, malnutrition, stroke with paralysis on left side, and need for assistance with personal care. Review of Resident #34's re-admission MDS Assessment, dated 6/20/25, revealed: He had a mental status score of 5 of 15 (indicating severe cognitive impairment). He had range of motion impairment of the upper and lower extremity on one side. He needed supervision for eating. Review of Resident #34's Care Plan, revised 6/24/25, revealed: Resident #34 was on a large portion diet with regular texture, regular consistency diet. All food should be in a divided plate or in bowls to prevent Resident #34 from throwing and breaking dishes. Fortified cereal for breakfast. The goal was Resident #34 would have adequate nutrition and fluid intake throughout the review date and receive 2 cups per meals of juice and water, coffee and milk in the morning, and water and fruit punch at lunch and supper. Interventions included to monitor and document intake and offer snacks within diet. Review of Resident #34's Care Plan, revised 6/20/25, revealed: Resident #34 was at risk for nutritional risk related to recent weight loss, Body Mass Index was 16.8 (underweight is below 18.5). The goal was Resident #34 will consume 75% or more of meal with no associate weight loss through next quarter, is large portion now and receives sandwiches on tray as well for lunch and supper. Interventions include Provide and serve diet as ordered. Review of Resident #34's Care Plan, revised on 11/27/23, revealed: Resident #34 had an ADL self-care performance deficit related to hemiplegia. The goal was Resident #34 was status would be maintained through the review date. The identified intervention for Eating was the resident required staff set-up or clean-up assistance with meals. Review of Resident #34's Care Plan, revised, 12/7/23 revealed: Resident #34 had a psychosocial well-being problem related to being dependent, behavior and ineffective coping. The identified goal was Resident #34 would demonstrate adjustment to nursing home placement by review date. Interventions included encouraging participation from the resident who depended on other to make his own decisions and to provide opportunities for the resident to participate in care. Review of Resident #34's weights revealed on 4/5/25 his weight was 130.6. On 6/5/25 his weight was 127.0. This was a 2.76% difference in two months that is only significant due to Resident #34 already being below the recommended Body Mass Index. Observation and interview beginning on 6/24/25 of the lunch meal at 11:42 a.m., it was noted Resident #34 had his tray. Resident #34 was placed in a geri-chair with his right side against the table (the dominant side that had movement). Resident #34's divided plate was observed in the center of the table when Resident #34 was at the corner of the table. Observation at 11:59 a.m. revealed Resident #34 was eating the salad which he could reach, but he could not reach the divided plate with the meat and potatoes on it. Observation at 12:06 p.m. revealed the DON offered Resident #34 a sandwich but did not notice his plate was out of reach. In an interview on 6/24/25 at 12:08 p.m., Resident #34 said he was hungry, and he did not eat his plate because he could not reach it. Resident asked surveyor for the plate to be moved. Surveyor moved the plate. Observation after the interview revealed Resident #34 could reach his plate, he immediately started eating the mashed potatoes. Observation at 12:16 p.m., the DON sat to assist Resident #34 to eat. At 12:28 p.m. Resident #34 got his sandwich and the DON pulled the table closer to where Resident #34 was so he could put the sandwich down. n an interview on 11:37 a.m., the DON stated she identified weight loss as an issue at the facility when she took over the facility a month prior and she was making plans every four weeks to see if there was improvement. The DON said that was currently her main clinical focus. The DON stated she just finished assessing what she thought was the issue and sent her recommendations to the Medical Director, changed the appetite stimulant used, is offering a different supplement and more double portions at meals. The DON said she struggled with the kitchen. In an interview on 6/26/25 at 11:53 a.m., the Regional RN stated there was no policy that addressed placing food within reach of the resident. The MDS Coordinator who was present stated, it's like going to a restaurant and they put the food on the other side of the table. In an interview on 6/26/25 at 11:57 a.m., the Administrator and VP of Regional Operations was informed of the meal observation of Resident #34 not having his plate for over half and hour and no one noticing. They were informed Resident #34 could eat food independently and was hungry. The two were told Resident #34 experienced weight loss and there was no policy addressing leaving the food out of reach. The VP of Regional Operations stated it was common sense for the aides to leave it within reach. In an interview on 6/26/25 at 12:05 PM, the Administrator stated weight loss did flag with the facility's Quality Assurance committee and was currently the DON's pet project.

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 to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #21) of 3 residents reviewed for infection control. CNA B failed to change her gloves and wash her hands after they became contaminated during incontinent care while assisting Resident #21. This failure could place resident's risk for cross contamination and the spread of infection. Finding include: Record review of Resident #21's admission record dated 06/25/2025 indicated he was admitted to the facility on [DATE] with diagnoses of dementia and muscle weakness. He was [AGE] years of age. Record review of Resident #21's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision [NAME] = Severely impaired - never/rarely made decisions. Urinary continence = Always incontinent. Bowel continence = Frequently incontinent. Record review of Resident #21's care plan dated 06/03/2025 indicated in part: Focus: The resident has occasional bladder incontinence. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Clean peri-area with each incontinence episode. During an observation on 06/24/25 at 03:16 PM, CNA A and CNA B performed incontinent care for Resident #21. CNAs assisted the resident to his bed, put on some gloves and then removed the residents brief which was wet with urine. CNA B took some wet wipes and wiped the resident's penis, scrotum and rectal area and her gloved hands which were observed to come in contact with the Resident #21's skin. CNA B then fastened the resident's brief, and put a pair of clean pants on the resident while still wearing the same gloves. During an interview on 06/24/25 at 03:24 PM, CNA B said she should have changed her gloves after she had performed the incontinent care and assisted with putting Resident #21's brief and pants on him. CNA B said not changing her gloves could lead to cross contamination which could lead to infections such as urinary tract infections. During an interview on 06/26/25 at 10:36 AM, the Administrator was made aware of the observation of incontinent care performed by CNA B. The Administrator said the CNA not changing her gloves after they had become contaminated could lead to cross contamination, and also could lead to the transmission of illnesses. The Administrator said they would have to conduct more training and in-services on infection control. During an interview on 06/26/25 at 10:50 AM, the DON said staff were expected to change their gloves once they became contaminated. The DON said the staff had to do that to prevent cross contamination. The DON said they would have to conduct more training and in-services on glove changes and handwashing, and also conduct more walk through rounds to monitor staff. Record review of the facility's policy titled Perineal Care dated 10/01/2021 indicated in part: To provide cleanliness and comfort to the resident, to prevent infections and skin irritation and to observe the resident's skin condition. Steps in the Procedure - Place the equipment on the bedside stand. Arrange the supplies so they can be easily reached. Wash and dry your hands thoroughly. Put on gloves. Wash perineal area, wiping from front to back Remove gloves and discard into designated container. Wash and dry your hands thoroughly. Record review of the facility's policy titled Infection Control and dated 01/15/2022 indicated in part: This communities' infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. This communities' infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteers, works and the public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status or payor source. The objective of our infection control policies and practices are to: prevent, detect, investigate and control infections in the community. Maintain a safe, sanitary and comfortable environment for personnel, residents, visitors and the public. All personnel will be trained on our infection control policies and practices upon hire and periodically thereafter including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities.

Based on interview and record review the facility failed to ensure allegation of abuse, the facility had evidence that alleged violation was thoroughly investigated but failed to report the results of investigation to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 1 resident (Residents #1) reviewed for investigating alleged violation of abuse. The facility failed to report evidence that a thorough investigation was conducted, failed to complete a provider investigative report (Form 3613A), and failed to report the results of the investigation when Resident #1 alleged abuse from CNA A which did not result in injury to Resident #1. These failures could place residents at risk for allegations of abuse and neglect not being thoroughly investigated by the facility and reported as required. Findings include: Record review of Resident #1's face sheet, dated 6/25/24, revealed Resident #1 was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included Acute Respiratory Failure with Hypercapnia (arterial oxygen, carbon dioxide, or both cannot be kept at normal levels), Ventricular Fibrillation (abnormal heart rhythm), Opioid dependence, Schizophrenia (mental disorder), Muscle Weakness, Muscle Wasting and Atrophy (wasting away of body part or tissue). Record review of Resident #1's MDS, dated [DATE], revealed Resident #1 had a BIMS score of 11 (moderate cognitively impaired), impaired visual functioning, fall risk, un-aware of safety risks. Record review of Resident #1's Care Plan, dated 4/7/24, revealed Resident #1 had impaired visual functioning and is at risk for decrease in ADLs and injuries. Resident #1 has behavior problems (refuses to listen to staff about smoke break times, redirection unsuccessful, low frustration tolerance. Schizoaffective disorder, Depression, high risk for falls and fractures, requires assistance with decision making, potential to be verbally aggressive towards staff, poor impulse control, limited physical mobility, elopement risk. Record review of Resident #1's progress notes, dated 5/26/24 at 2:40pm revealed, LVN B documented, this nurse witnessed resident verbally aggressive with CNA due to his smoke break. This resident bad-mouthing CNA because resident demanding to be taken out for a smoke CNA stated he would take him out to give him a minute to finish doing what he was doing resident then became loud demanding to be taken out, came around nurse's station and grabbed his cigarettes' and stated he would take himself. This nurse heard door alarm from smoking door, upon walking down hallway noted residents and staff down the hallway, this resident noted to be in the middle of the hallway, when he noticed this nurse he came towards me, upset, stating he wanted to report the male CNA A because he had put his hands on him, this nurse and resident continued on to the nurses station where resident stating he wanted to call the police, resident taken aside and assessment done, no bruising, no redness, no swelling noted to resident, then proceeded to report what had occurred, this nurse notified abuse coordinator and DON, resident then noted to go up to the CNA stating he would make sure and take his job from him, resident redirected and relocated, assisted outside by this nurse to take a smoke break and calm down, attempted to notify resident's family member of incident, no answer, resident stated he is on a cruise but that he does not want his family to know of incident. Record review of facility incident intake #506758, reported to HHSC on 5/26/24 by facility Administrator, incident category: Abuse. Narrative of incident intake #506758, 'Resident #1 asked to be taken out to smoke break, CNA A told Resident #1 that he would, but he needed to finish his charting before he went, and he would need a couple of minutes to finish it. CNA A turned and asked LVN C to take the smokers out to smoke. LVN C began to take the smokers down the hall while CNA A finished his charting. When CNA A was finished, he went down the smoker's hallway and Resident #1 stands up on his scooter to confront CNA A. Resident #1 told CNA A I will get our license and When I get done with you won't have anything left. CNA A said that he saw Resident #1 stand up on his scooter and become unsteady on his feet. CNA A put his hand under Resident #1's elbow to support him in sitting down in his chair. Resident #1 then began to say that CNA A had abused him. During an interview on 6/25/24 at 1:00pm with Resident #1 stated the facility and staff were good this was a good place, and they take care of them. Resident #1 did re-call incident on 5/26/24 at 2:30pm, Resident #1 stated he was ready to go smoke, and CNA A told him that he was not taking resident outside to smoke with the other residents. Resident #1 stated he had no idea why CNA A was not letting him go with them. Resident #1 stated for no reason CNA A pushed him back into his wheelchair, Resident #1 denied yelling or cussing at CNA A. Resident stated that CNA A was in front of him and grabbed him under his arms and pushed him. Resident #1 stated he was not hurt but was angry. Resident #1 stated he told the charge nurse, and the nurse checked him out and he was fine, he did not get hurt. Resident #1 stated he has never had any problems with CNA A before and has never seen or heard of any problems in the facility, Resident #1 stated this was a good facility and staff. Resident #1 stated that the DON and Administrator sent CNA A home and he has not come back. On 6/25/24 at 4:10pm Resident #1 approached surveyor and stated he (Resident #1) went a little overboard on 5/26/24 and acted out, Resident #1 stated sometimes he can't control his anger and yells at people. Record review of CNA A's statement dated 5/26/24 (CNA A did not return to facility after incident and self-terminated and did not reply to phone calls by surveyor). CNA A stated he told Resident #1 that he will take out residents to smoke in a few minutes. CNA A stated Resident #1 started yelling and calling him names, then Resident #1 stood up in his scooter and yelling at CNA A and began to fall forward, and CNA A grabbed Resident #1 and put him back in his scooter. LVN B came down hall, Resident #1 stated I pushed him, and he want to file abuse charges. CNA A denied allegations. Interview on 6/26/24 at 10:30am LVN B stated she witnessed Resident #1 yelling at CNA A to take them out to smoke. LVN B stated she was walking down hall towards CNA A and Resident #1, they were by the smoking exit door, LVN B stated she did not see CNA A grab or touch Resident #1. LVN stated Resident #1 came rolling up towards LVN stating CNA had pushed him and he wants to report abuse. LVN B stated she assessed resident found no redness or bruising, no injuries, Resident #1 stated he was not injured. LVN B stated she called Administrator and DON to report incident, notified resident's physician and tried to contact resident's family member but had no answer, resident stated they were on a cruise. Record review on 6/25/24 at 2:25pm Resident #2, [AGE] year-old male, BIMS of 11 (moderately cognitive impaired) stated he witnessed the incident. He stated Resident #1 stood up and got in CNA A's face saying you don't know who you are missing with. Resident #2 stated CNA A did not put his hands on Resident #1, Resident #1 did almost fall, and CNA A grabbed him and kept him from falling. Resident #2 did not know why Resident #1 was upset. Resident #2 stated he has never seen or heard of CNA being disrespectful to anyone, all the staff were nice. Interview on 6/25/24 at 1:55pm Administrator stated she self-reported incident on 5/26/24 to HHSC. In-service was conducted by DON on 5/26/24 over Abuse and who to report it to. The Administrator stated she did the investigation, took statements but did not know why she did not complete and turn in the 3613A Provider Investigation Report form as required in 5 days. The Administrator stated she and the DON discussed and decided the incident was inconclusive, but CNA A did not come back to facility, self-terminated. Record review of facility's Abuse/ Neglect Policy for Reporting: Abuse Reporting Policy date 1/1/23 Page 4, 'The abuse coordinator with the Director of Nursing/designee will investigate all allegations and use the appropriate forms to document the investigation and turn it into HHS within 5 calendar days.'

Based on interview and record review, the facility failed to notify the resident representative when the resident had a change in his psychosocial status for one (Resident #1) of four residents reviewed for changes in condition. The facility failed to inform Resident #1's responsible party when he ran out of the medication Risperidone or of his ongoing aggressive behavior. The facility failed to inform Resident#1's physician that when he ran out of the medication Risperidone and get a new order for the medication at the family's request. This failure could place residents at risk for not having their representative notified or not receiving relevant medical information when there is a change of condition. Findings included: Review of Resident #1's Admission Record, dated 5/16/24, revealed he was a [AGE] year-old male who was a respite resident originally admitted to the facility on [DATE] with a most recent admitted [DATE] with a diagnosis which included Traumatic Brain Injury and Quadriplegic Cerebral Palsy. Resident #1 was discharged on [DATE]. Review of Resident #1's Order Summary Report, dated, 5/16/24, revealed orders including Risperidone 1 mg in liquid form twice a day for traumatic brain injury. Resident #1 was not in the facility long enough for a Minimum Data Set to be completed. Review of Resident #1's Care Plan revealed: Dated 9/2/21: Focus that Resident #1 may have adverse consequences from the use of psychotropic medications as evidenced by disease process Traumatic Brain Injury and take Risperidone as ordered. The identified goal was Resident #1 would remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension (low blood pressure), gait disturbance, constipation/impaction, or cognitive/behavioral impairment through the review date. Identified interventions included Administer psychotropic medications as ordered by physician. Dated 12/15/23: Focus The resident is on an antipsychotic medication Risperidone related to Traumatic Brain Injury. The goal was the resident will remain free from adverse reactions related to antipsychotic medication therapy. Interventions included: administer medications as ordered and obtain consent from resident or responsible party prior to medication use. Dated 12/17/23 The resident has a behavior problem. Hits/grabs staff or residents related to low frustration tolerance. The identified goal was: the resident will have fewer episodes of hitting or grabbing by review date. Identified interventions included: administer medications as ordered. Dated 4/14/24 Focus: The resident has the potential to be physically aggressive (hits, kicks, throws things) related to poor impulse control. The goal was the resident will demonstrate effective coping skills through the review date. Interventions included: Administer medications as ordered Dated 4/17/24 The resident has a psychosocial well-being problem related to Quadriplegic Cerebral Palsy. The identified goal was: the resident demonstrate adjustment to the nursing home placement through review date. Identified interventions included: increase communication between resident/ family/ caregivers about care and living environment. Explain all procedures and treatments, medications, condition, all changes, rules, options and provide opportunities for the resident and family to participate in care. Review of Resident #1's April 2024 MAR revealed: Saturday 4/13/24 at 8 p.m. = (Administration note Time 4:58 p.m. revealed: med aide approach resident for meds, he swung left arm and knock meds out of hand, spit, and hitting table with fist. Med aide informed nurse. Sunday 4/14/24 at 8 a.m. = (Administration note time 3:38 p.m. meds refused, resident very combative and informed nurse) 4/14/24 at 8 p.m. = resident refused the medication Wednesday 4/17/24 at 8 p.m. = resident refused the medication Thursday 4/18/24 at 8 p.m. = resident refused the medication Sunday 4/21/24 at 8 am. = resident refused the medication Tuesday 4/23/24 at 8 a.m. = (administration note, time 8:54 a.m. administration note - notified family for meds) 4/23/24 at 8 p.m. = 9 Wednesday 4/24/24 at 8 a.m. = 9 4/24/24 at 8 p.m. = (administration note, time 8:37 p.m. awaiting from family) Thursday 4/25/24 at 8 p.m. =9 (administration note, time 9:09 p.m. awaiting from the family) Friday 4/26/24 at 8 p.m. = (administration note, time 8:25 p.m. awaiting from the family) Sunday 4/28/24 at 8 a.m. = (administration note, time 1:45 resident not very cooperative not taking meds and combative, informed nurse) Monday 4/29/24 at 8 a.m. = resident refused the medication (administration note, time 8:16 p.m. awaiting from family) 4/29/24 at 8 p.m. = (no note given for why resident did not get the medication) Review of Resident #1's Clinical Notes revealed: 4/13/24 5:55 p.m. Behavior Note: Resident refused to eat all meals. Refused medications. Threw medications on MA. Slamming hand onto table and swing fist at staff. 4/20/24 10:47 a.m. Behavior Note: Staff approached this nurse voiced resident is being combative, instructed staff to sit resident alone this nurse approached resident with bilingual nurse the second nurse spoke to him in Spanish offered him breakfast and coffee. Resident took his hat off and began to swing at second nurse. Attempted to give him lorazepam (an anti-anxiety medication) as needed. Resident Refused and knocked cup out of the nurse's hand. At this time staff stepped back and allowed resident to sit alone in front of tv in common area. Other residents kept at a distant. (no documentation of family notified of behavior) 4/26/24 7:38 a.m. Behavior Note: Resident being aggressive with staff. Hit CNA in the stomach as she walked by resident. When this nurse walked by punched cart with fist. When medication aide went to give medications, resident flipped off by resident. 4/27/24 12:06 p.m. Nurse's Note: Resident admitted for respite care. Resident admitted with medication from home. Risperidone on hand depleted (facility out of medication). Attempted to notify parent. No answer. notified Care Giver of needed medication stated can't you order it? The pharmacy here closes at noon, we can't get it. Advised that typically respite residents supply their own meds and long-term care residents' medications are supplied by facility pharmacy. Also advised that resident will miss multiple doses until medication is able to be obtained which will be more difficult to obtain a liquid medication. replied, ok then. Review of the 24-hour report showed no documentation that the family was notified of Resident #1's ongoing behaviors or that he was running out of Risperidone. On 4/12/24 (day of admission) it documented he was admitted for respite care for three weeks. Review of the Discharge Summary dated 5/1/24 at 1:15 p.m. revealed Resident discharged home with family. Took belongings with resident and medications. Review of the CNA behavior monitoring Kardex revealed Resident #1 demonstrated multiple physical and/or disruptive behaviors daily. Review of Resident #1's Admission Contract signed by the Resident/Family revealed the family signed they gave consent for the Medical Director to be the resident's physician for the duration of the resident's stay and for the facility to be in charge of pharmacy service. (The family signed the same contract every other admitting resident signed.) Interview on 5/15/24 at 12:29 p.m. the Administrator stated Resident #1 was a private pay resident and there were issues with his medications. She stated his family was supposed to bring his Risperidone and they were not able to bring it. The Administrator stated Resident #1 used the liquid version of the medication and the facility's pharmacy did not provide that. The Administrator stated they explained to the family they would have to bill the family for the medication if they ordered it. The Administrator stated Resident #1 was frequently aggressive to staff and would not eat or drink. The Administrator said on the last day he was at the facility; Resident #1 tore the arm and tip back bar off his wheelchair. The Administrator said Resident #1 was a TBI and was a respite resident. She stated the facility had had him prior, but this visit was a bit longer than previous stays. During an interview on 5/16/24 at 1:42 p.m. CNA A said there was a resident on her hall that would hit them. She stated the expectation was for 2 people to go into the room to assist the resident and explain what you were doing. CNA A said if that did not work to step away and come back when the resident was calmer. CNA A said Resident #1 would refuse to take his medication and all the nurse would say was not to agitate him. She said he was only at the facility for a few weeks. CNA A said he was calmer with the girls who would speak Spanish to him and explain everything they were doing, every time they were doing it. During an interview on 5/16/24 at 2:45 p.m. MA B stated the ordering process for medications was the MA would make a list of medications they were running out of and give it to the nurse and the nurse would follow up with it. MA B stated the facility would usually get the medication the next day unless it was a narcotic they needed to go to the doctor for or the resident was hospice and hospice needed to bring the medication. MA B said she did not know why a resident would go without medication because she believed the pharmacy was open on the weekends. MA B said she did not know of any special circumstances that would prevent a resident from getting medications. Interview on 5/17/24 at 12:47 p.m. Resident #1's family stated they used the facility for respite care for years without issue, so they continued that. She said the facility called one time to say he had behaviors and she said she told them to put him to bed with his cards and he would calm down. The family stated the facility dealt with it and Resident #1 started eating. The family member said the following day Resident #1 did fine and the family did not hear anything from the facility, so they thought things were fine. The family said the family visited to check on Resident #1 and he was happy, and they were fine and he was eating; then that Saturday they called and said he was out of his Risperidone. Resident #1's family member said they thought why was the facility calling the family now when the drug store was closed and the family lived several hours away. The family said when they went to pick up Resident #1 no one told them anything about how Resident #1 did at the facility. Interview on 5/17/24 at 3:47 p.m. the Administrator stated the respite contract was different from the regular contract in that the facility did not provide the resident's medications. The DON said she did not know where it documented in the respite contract, only that was what she was told. The Administrator said if a resident was private pay they were still under their doctor's care so if they needed anything they would be seen by the doctor. The DON added the facility's doctor did see Resident #1 while he was at the facility. The DON said they facility did reorder Resident #1's Risperidone but the pharmacy did not provide the liquid. The DON said the facility could have got an order for the Risperidone and crushed the medication. The Administrator explained the family visited twice and Resident #1 was very happy they visited. The Administrator said Resident #1 said when the family came the second time Resident #1 thought he was going to go home and when he did not his behavior escalated. The DON said that Saturday they called the and notified the caregiver the facility was out of the Risperidone. The DON stated the said they lived in a town 3 hours away and the pharmacy there was closed so the facility needed to get the medication. The DON said if the family said if Resident #1 got combative to give him flash cards and put to bed. The DON said this did not work to calm him down. The DON stated the visited the first weekend and brought him a milkshake. The DON said Resident #1 drank all of it and they told the family he was not eating, was being aggressive, and not taking his medication, and the family said that was fine (there is no documentation of this communication). The DON stated the family visited a second time and Resident #1 became so excited because he thought he would be going home so when he did not go home he threw a fork at staff and that Saturday he was getting all out. The DON said the nurses called the said the city's pharmacy was closed so the facility needed to get the medication. The DON said the facility got the medication, but it took their pharmacy a while to get the medication which was not perfect. The DON stated there was no order to crush the Risperidone and Risperidone was not in the facility's emergency medication system. The DON said Resident #1 was not hurting himself or other so did not need the antipsychotic medication they did have in the emergency medication system. The DON said the nurses did not document they called the family. The DON said the nurses were encouraged to call the family and talked to them twice. The DON agreed the family should have been contacted more often and she did not know why they were not. She said the family should have been contacted when Resident #1 stopped eating again and when his behavior escalated. The Administrator stated she was not sure of the exact policy but the family should have been notified when the medication was low and not out and when Resident #1 stopped eating. The Administrator said there were a lot of behaviors, behaviors, he's a repeat respite, I don't know if it's continued decline. The Administrator added Resident #1 never got comfortable at the facility with the respite visits. The DON said nothing worked to calm Resident #1 down and the facility did not know the family was upset with the facility's care until the family contacted them two days after the discharge. Review of the facility's policy and procedure on Change in a Resident's Condition or Status, Revised May 2017, revealed: Policy Statement: our facility shall promptly notify the resident, his or her Attending Physician, an representative (sponsor)(of changes in the resident's medical/mental condition and/or status (e.g. changes in level of care, billing/payments, residents rights etc.) Policy Interpretation and Implementation The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): refusal of treatment or medications two (2) or more consecutive times. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: there is a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. The nurse will record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of one (Resident #1) of four residents reviewed for availability of medications. The facility failed to obtain and administer the antipsychotic Risperidone fifteen (15) times between 4/23/24 and 5/1/24 per physician's orders to Resident #1. This failure puts residents at risk of not receiving prescribed medications and experiencing behaviors or other symptoms of diagnosed conditions. Findings included: Review of Resident #1's Admission Record, dated 5/16/24, revealed he was a [AGE] year-old male was originally admitted to the facility on [DATE] for respite services with a most recent admitted [DATE] with a diagnosis which included Traumatic Brain Injury and Quadriplegic Cerebral Palsy. Resident #1 was discharged on [DATE]. Review of Resident #1's Order Summary Report, dated, 5/16/24, revealed orders including Risperidone 1 mg in liquid form twice a day for traumatic brain injury beginning 6/7/23. Review of Resident #1's Care Plan revealed: Dated 9/2/21: Focus that Resident #1 may have adverse consequences from the use of psychotropic medications as evidenced by disease process Traumatic Brain Injury and take Risperidone as ordered. The identified goal was Resident #1 would remain free of psychotropic drug related complications, including movement disorder, discomfort, hypotension, gait disturbance, constipation/impaction, or cognitive/behavioral impairment through the review date. Identified interventions included Administer psychotropic medications as ordered by physician. Dated 12/15/23: Focus The resident is on an antipsychotic medication Risperidone related to Traumatic Brain Injury. The goal was the resident will remain free from adverse reactions related to antipsychotic medication therapy. Interventions included: administer medications as ordered and obtain consent from resident or responsible party prior to medication use. Review of Resident #1's April 2024 MAR revealed: Tuesday 4/23/24 at 8 a.m. = (administration note, time 8:54 a.m. administration note - notified family for meds) 4/23/24 at 8 p.m. = (no explanation on why medication not given) Wednesday 4/24/24 at 8 a.m. = (no explanation on why medication not given) 4/24/24 at 8 p.m. = (administration note, time 8:37 p.m. awaiting from family) Thursday 4/25/24 at 8 p.m. = (administration note, time 9:09 p.m. awaiting from the family) Friday 4/26/24 at 8 p.m. = (administration note, time 8:25 p.m. awaiting from the family) Sunday 4/28/24 at 8 a.m. = (administration note, time 1:45 resident not very cooperative not taking meds and combative, informed nurse) Monday 4/29/24 at 8 a.m. = resident refused the medication (administration note, time 8:16 p.m. awaiting from family) 4/29/24 at 8 p.m. = (no explanation on why medication not given) Review of Resident #1's Clinical Notes revealed: 4/27/24 12:06 p.m. Nurse's Note: Resident admitted for respite care. Resident admitted with medication from home. Risperidone on had depleted (the facility ran out of medications). Attempted to notify the paren. No answer. Caregiver notified of needed medication. stated can't you order it? The pharmacy here closes at noon, we can't get it. Advised Caregiver that typically respite residents supply their own meds and long-term care residents' medications are supplied by facility pharmacy. Also advised caregiver that resident will miss multiple doses until medication is able to be obtained which will be more difficult to obtain a liquid medication. Caregiver replied, ok then. Review of the 24-hour report showed no documentation that the family was notified of Resident #1's running out of Risperidone. On 4/12/24 (day of admission) it documented he was admitted for respite care for three weeks. 5/1/24 1:15 p.m. Discharge Summary Resident discharged home with family. Took belongings with resident and medications. Review of Resident #1's Admissions Contract signed by the Resident/Family on 9/2/21 revealed the family signed they gave consent for the Medical Director to be the resident's physician for the duration of the resident's stay and for the facility to be in charge of pharmacy service. (The family signed the same contract every other admitting resident signed.) Interview on 5/15/24 at 12:29 p.m. the Administrator stated Resident #1 was a private pay resident and there were issues with his medications. She stated his family was supposed to bring his Risperidone and they were not able to bring it. The Administrator stated Resident #1 used the liquid version of the medication and the facility's pharmacy did not provide that. The Administrator stated they explained to the family they would have to bill the family for the medication if they ordered it. The Administrator stated Resident #1 was frequently aggressive to staff and would not eat or drink. The Administrator said on the last day he was at the facility; Resident #1 tore the arm and tip back bar off his wheelchair. The Administrator said Resident #1 was a TBI and was a respite resident. She stated the facility had had him previously, but this visit was a bit longer than previous stays. During an interview on 5/16/24 at 2:45 p.m. MA B stated the ordering process for medications was the MA would make a list of medications they were running out of and give it to the nurse and the nurse would follow up with it. MA B stated the facility would usually get the medication the next day unless it was a narcotic they needed to go to the doctor for or the resident was hospice and hospice needed to bring the medication. MA B said she did not know why a resident would go without medication because she believed the pharmacy was open on the weekends. MA B said she did not know of any special circumstances that would prevent a resident from getting medications. Interview on 5/17/24 at 12:47 p.m. Resident #1's family stated they used the facility for respite care for years without issue, so they continued that. She said the facility called one time to say he had behaviors and she said she told them to put him to bed with his cards and he would calm down. The family stated the facility dealt with it and Resident #1 started eating. The family member said the following day Resident #1 did fine and the family did not hear anything from the facility, so they thought things were fine. The family said the family visited to check on Resident #1 and he was happy, and they were fine, and he was eating; then that Saturday they called and said he was out of his Risperidone. Resident #1's family member said they thought why was the facility calling the family now when the drug store was closed, and the family lived several hours away. The family said when they went to pick up Resident #1 no one told them anything about how Resident #1 did at the facility. Interview on 5/17/24 at 3:47 p.m. the Administrator stated the respite contract was different from the regular contract in that the facility did not provide the resident's medications. The DON said she did not know where it documented in the respite contract, only that was what she was told. The Administrator said if a resident was private pay, they were still under their doctor's care so if they needed anything they would be seen by the doctor. The DON added the facility's doctor did see Resident #1 while he was at the facility. The DON said they facility did reorder Resident #1's Risperidone but the pharmacy did not provide the liquid. The DON said the facility could have got an order for the Risperidone and crushed the medication. The DON said that Saturday they called the and notified the Caregiver the facility was out of the Risperidone. The DON stated the said they lived in a town 3 hours away and the pharmacy there was closed so the facility needed to get the medication. The DON said if the family said if Resident #1 got combative to give him flash cards and put him to bed. The DON said this did not work to calm him down. The DON stated the visited the first weekend and brought him a milkshake. The DON said Resident #1 drank all of it and they told the family he was not eating, was being aggressive, and not taking his medication, and the family said that was fine (there is no documentation of this communication). The DON said the nurses called the said the city's pharmacy was closed so the facility needed to get the medication. The DON said the facility got the medication, but it took their pharmacy a while to get the medication which was not perfect. The DON stated there was no order to crush the Risperidone and Risperidone was not in the facility's emergency medication system. The DON said Resident #1 was not hurting himself or others so did not need the antipsychotic medication they did have in the emergency medication system. The DON said the nurses did not document they called the family. The DON said the nurses were encourage to call the family and talked to them twice. The Administrator stated she was not sure of the exact policy but they family should have been notified when the medication was low and not out. Review of the facility's policy and procedure on Unavailable Medications, revised August 2020, documented: Medications used by residents in the nursing facility may be unavailable for dispensing from the pharmacy on occasion. This may be due to the pharmacy being temporarily out of stock of a particular product, a drug recall, or manufacturer's shortage of an ingredient, or may be a permanent situation due to the medication no longer being produced. The facility must make every effort to ensure that medications are available to meet the needs of each resident. Procedures: The pharmacy staff shall: Notify nursing staff that the order product(s) is/are unavailable. Notify nursing staff of when it is anticipated that the drug(s) will become available Suggest alternative, comparable drug(s) and dosage of drug(s) that is/are available. The nursing staff shall: Notify the attending physician (or on-call physician when applicable of the situation and explain the circumstance, expected availability, and alternative therapy(ies) available. If the facility nurse is unable to obtain a response from the attending physician or on-call physician, the nurse should notify the nursing supervisor and contact the Facility Medical Director for orders and/or direction. Obtain a new order and cancel/discontinue the order for the non-available medication. Notify the pharmacy of the replacement order.

Based on observations, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 3 of 4 halls (Hall 300, Hall 400, and Hall 500) reviewed for accidents and supervision. 1. The temperature reading for Hall 300 shower room sink was 119 F. 2. The temperature reading for Hall 400 shower room sink was 141.3 F and for the shower itself was 137.9 F. 3. The temperature for Hall 500 shower was 136 F. 4. The temperature readings for Hall 500 resident sinks were in temperature ranges from 130 F to 135 5. The temperature of Hall 500 hot water heater was 140 F. An Immediate Jeopardy (IJ) situation was identified on 04/22/2024. While the IJ was lowered on 04/23/2024 at 3:00 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of a pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. This failure could place residents at risk for 3rd degree burns causing serious injury, serious harm, hospitalization s, impairment and/or death. Findings include: Resident #51 Record Review of the Resident #51's Face Sheet dated 04/24/2024, revealed he was a [AGE] year-old male, admitted to the facility on [DATE] with initial admission on 01/20/2022. He had a Diagnoses of Schizophrenia, dementia, anxiety disorder, and depression. Record Review of Resident #51's MDS assessment, dated 03/14/2024, revealed a BIMS score of 06 (severely impaired cognition). During an interview on 04/21/24 at 12:54 PM Resident #51 stated he used the shower on Hall 500 and the showers were too hot when being showered. He stated he would complain to the CNA that showered him but in doing so, it had not lowered the temperatures of the water for future showering. Resident #12 Record Review of the resident #12's Face Sheet dated 04/24/2024, revealed he was a [AGE] year-old-male, admitted to the facility on [DATE], with diagnoses of muscle weakness and wasting, difficulty walking, depression, and tobacco use and heart disease. Resident #12's MDS, dated [DATE], revealed a BIMS score of 11 (moderately impaired). Review of Resident #12's Care Plan dated 10/10/2023 revealed: Focus-The resident has coronary artery disease (CAD) r/t Hypertension . Goal-The resident will be free from/sx of complications of cardiac problems through the review date. Interventions-Educate the resident/family/caregivers about: factors which might precipitate irregular heart rate: Stress, Activity. Focus- I have an ADL self-care performance deficit r/t disease process. Impaired balance and Limited Mobility. Goal-The resident will show appropriate self-care progress by review date. Interventions- BATHING/SHOWERING: The resident requires limited staff assistance with bathing. During an interview on 04/21/24 at 4:18 PM, Resident #12 statedhe used the shower on Hall 500 and that he felt as if the water was too hot in the shower and would burn someone if they were not careful. An observation made by the surveyors on 04/21/2024 between 5:05 PM and 5:25 PM, with [NAME] Model 884ON Digital Thermometer, revealed; 1. The temperature reading for Hall 300 shower room sink was 119 F. 2. The temperature reading for Hall 400 shower room sink was 141.3 F and for the shower itself was 137.9 F. 3. The temperature for Hall 500 shower was 136 F. 4. The temperature readings for Hall 500 resident sinks were in temperature ranges from 130 F to 135 5. The temperature of Hall 500 hot water heater was 140 F. During an interview on 04/21/24 at 5:22 PM, the DON was present during 400 hall temp. She voiced that she felt the water could have burnt residents. During an interview on 04/21/2024 at 5:30 PM, CNA-F stated she did not know what the water temperature should be. She stated that having water too hot could lead to residents being burned because the residents with memory difficulty would not know to turn on the cold water and feel pain differently. During an observation on 04/21/2024 at 7:18pm, Hall 400 water heater revealed temperature of 140 F. The DON then lowered the temperature to below 130 F During an observation on 04/21/2024 at 7:21pm, Hall 300 water heater revealed temperature of 120 F. The DON was unable to lower the temperature due to the gauge being locked. During an observation on 04/21/2024 at 7:22pm, Hall 200 water heater revealed temperature of 120 F. The DON then lowered the temperature to 110 F During an observation on 04/21/2024 at 7:32pm, Hall 500 water heater revealed temperature of 140 F. The DON turned the hot water off due to inability to lower the temperatures. During an interview on 04/21/2024 at 7:45 PM, the DPP stated he checked the water temperatures using a General 8:1 Non-Contact Infrared Thermometer. He stated the thermometer he was told to use had no probe to insert into running water but had checked the temperatures weekly. He also stated that the only policy the facility used for water checking the water temperatures were regarding monitoring for Legionella's and not specifically maintaining water temperatures. During an observation on 04/21/2024 at 8:07 PM, the facility temperature of the Hall 200 shower measured, by DPP, at 81 F with the General 8:1Non-Contact Infrared Thermometer. The survey teams measured temperature, with a [NAME] Model 884ON Digital Thermometer, was 106.3 F, a 25.3 difference. During an observation on 04/21/2024 at 8:12pm, the facility temperature of Hall 500 shower measured, by DPP, was 80 F with the General 8:1 Non-Contact Infrared Thermometer. The survey team temperature with a [NAME] Model 884ON Digital Thermometer was 104.9 F. a 24.9 difference. During an interview on 04/21/2024 at 12:06 PM, the ADMN stated that the DPP had monitored the water temperatures for the showers and resident rooms. She stated she was supposed to had monitored the DPP but had assumed they were correct as the numbers were between 100-110 degrees F but not knowing his infrared thermometer was inaccurate. The ADMN stated the negative impact to residents could have possibly been burned, as well as cause rashes since they have sensitive skin. She stated the failure occurred with faulty equipment. The ADMN stated her expectations were to monitor and regulate the water temperatures to stay between 100-110. Record Review of facility's undated policy titled FACP (Focused Acute Care Partners), revealed: Components: 3B. Temperature checks will be performed in each zone via showers, sink faucets at least weekly; information will be entered into the life safety logs for monitoring of changes. Water temperature must be between 100-110 at the point of use for resident areas .temperatures will be adjusted if temperature is out of range. If unable to correct the temperature the Executive Director of operations will be notified for further interventions. Review of US Consumer Product Safety Commission Avoiding Tap Water Scalds accessed on 05/09/2024 at http://efaidnbmnnnibpcajpcglclefindmkaj/https://www.cpsc.gov/s3fs-public/5098.pdf revealed: Most adults will suffer third-degree burns if exposed to 150 degree water for two seconds. Burns will also occur with a six-second exposure to 140 degree water or with a thirty second exposure to 130 degree water. Even if the temperature is 120 degrees, a five minute exposure could result in third-degree burns. This was determined to be an Immediate Jeopardy (IJ) on 04/22/2024. The Administrator was notified on 04/22/2024 at 2:36 pm that an Immediate Jeopardy was identified, was requested at that time. The Administrator was provided with the IJ template on 04/22/2024 at 2:36 pm. The following Plan of Removal was accepted on 04/23/2024 at 8:10 pm and included: The facility failed to maintain an environment that was free from accidents and hazards for 3 of 4 (300, 400, and 500) halls and failed to maintain hot water temperatures below 110 F. This had the potential to affect 50 residents that were dependent on water in resident rooms and shower rooms on 3 of 4 halls that could put residents at risk for severe injury, serious harm, hospitalization , impairment and/or death. The medical director was notified of the immediate jeopardy related to hot water on 04/22/2024 at 4:09 p.m. As of 4/22/2024 the facility has achieved temperatures below 110 degrees Fahrenheit on hall 300, 400 and 500. Facility will maintain hot water temperatures below 110 F on 300, 400, and 500 and will be checked three times daily for 7 days, twice daily for 30 and then once daily thereafter. Implemented 4/22/24. An ongoing in-service will be done until all staff has been in-service. The Corporate Physical Plant Director will Inservice the Executive Director of Operation (EDO), Director of Physical Plant (DPP), Director of Clinical Operations (DCO) and Assistant Director of Clinical Operations, (ADCO) via spoken in- service/demonstration: Checking water temperatures and the ranges to be within 100-110. A sign in sheet will reflect an indication of understanding. Completed 4/22/24. The EDO and DPP will in-service all staff to include administration (IDT team), dietary, housekeeping, laundry and clinical (nurses and nurse aides) via spoken in- service/demonstration prior to the start of their next shift: Checking water temperatures and the ranges to be within 100-110 degrees Fahrenheit using probe style thermometer. A sign in sheet will reflect an indication of understanding. Completed 4/22/24. ALL newly hired and agency staff will be trained in Checking water temperatures and the ranges to be within 100-110 degrees Fahrenheit using probe style thermometer. A sign in sheet will reflect an indication of understanding. If shower is outside of the acceptable range the temperatures the shower will be put OUT OF ORDER until the acceptable temperature can be obtained. The facility will provide in-service documents, temp logs and signature pages. New thermometers have been purchased and will be used within the manufacturer's limits. Skin sweeps by ADCO and DCO will be conducted on 50 out of 70 residents to ensure residents are free from burn marks. Any findings of burn marks will be addressed with pertinent first aid and physician notification protocol. An incident report will be completed along with family notification. Completed 4/22/24. Focused Partner Rounds to be done daily by IDT team to address any issues or concerns with water temperature during showers. If residents voice any concerns with water temperature immediate testing will be conducted to ensure water is within appropriate ranges. Implemented 4/23/24. This practice will be reviewed monthly with the QA committee to ensure we comply with hot water temperatures. Responsible: Corporate Director of Physical Plant, EDO, DPP, DCO Surveyors monitored the facility's Plan of Removal and confirmed it was sufficient to remove the IJ through observations, interview, and record reviews from 04/23/2024 at 9:15 a.m. to 04/23/2024 at 3:00 p.m. as follows: During an interview on 4/23/2024 at 9:56 a.m., the EDO stated she had been in-serviced by the corporate PPD. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During an interview on 4/23/2024 at 9:58 a.m., the DPP stated he had been in-serviced by the corporate PPD. He stated he understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During an interview on 4/23/2024 at 9:59 a.m., the DCO stated she had been in-serviced by the corporate PPD. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During an interview on 4/23/2024 at 10:00 a.m., the ADCO stated she had been in-serviced by the corporate PPD. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:08 a.m., CNA-D stated she had been in-serviced by the DCO. She stated that she worked on the night shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:12 a.m., LVN-H stated she had been in-serviced by the DCO. She stated that she worked on the day shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:14 a.m., LVN-I stated she had been in-serviced by the DCO. She stated that she worked on the night shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:16 a.m., CNA-C stated she had been in-serviced by the DCO. She stated that she worked on the night shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:17 a.m., HK-K stated she had been in-serviced by the DCO. She stated that she worked on the night shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:19 a.m., Laundry stated she had been in-serviced by the DCO. She stated that she worked on the night shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During a phone interview on 4/23/2024 at 10:25 a.m., the DM stated she had been in-serviced by the DCO. She stated that she worked on the night shift. She stated she understood the education and that water temperatures needed to be maintained between 100 F and 110 F. During an interview on 04/23/2024 at 10:30 a.m., the EDO stated that the facility had not hired any new staff since the IJ was called on 04/22/2024. She stated that the facility had one agency staff who was in-serviced and would provide proof of in-service on document sign-in sheet. Record review of the in-service signature sheets were verified of the agency staff signature. During an interview on 04/23/24 at 11:53 AM, the ADON (ADCO) and DON (DCO) verified that they both performed skin sweeps to all the residents. The DON stated that it was during the smoking break and some of the 400 hall residents were outside, but they came back and performed the skin assessments for them later. Both stated that they would verify that they observed each other performing. Reviewed list of residents with skin assessments performed. Verified skin assessments were documented in the electronic charts for all 70 residents. Random interviews with 6 residents who verified their skin was assessed the night of 04/22/2024. Reviewed in-service titled: Water temperatures dated 04/22/2024 revealed the administration (IDT team), dietary, housekeeping, laundry and clinical (nurses and nurse aides). The education included: Facility water temperatures should be between 100-110 degrees Fahrenheit in resident use areas. Reviewed in-service information and signature sheets for in-service reading dated 04/22/2024: Facility water temperatures must be between 100-110 degrees Fahrenheit in resident use areas. Water temperatures must be checked three times daily for 7 days, twice daily for 30 days and then once daily thereafter. Water temperatures must be checked with a calibrated probe style thermometer. Verified EDO, DPP, DON (DCO), and ADON (ADCO) signatures. Reviewed in-service information and signature sheets for in-services titled Temperatures of Showers dated 04/22/2024 revealed: Temperatures of Showers should be between 100-110 degrees Fahrenheit. If the resident states it is too hot, stop and report to DON/ADMN. We check the temperature with a temperature probe, report broken/hot water or sinks in maintenance log. Comparison of schedule from 04/22/2024- 04/23/2024 including day and night shift revealed all scheduled staff were educated prior to working their next shift. Reviewed water temperature logs that included temperature checks for hall 200, 300, 400, 500 sinks and shower. Those checks were performed on 04/22/2024 at 8:00 AM, 12:45 PM, 3:10 PM, and 7:00 PM, with all temperatures in range. Further review revealed temperature checks on 04/23/24 at 8:00 AM and were within range between 100-110 degrees F. During an observation on 04/23/24 at 11:00 AM, temperature checks were performed on showers and sinks on hall 200, 300, 400, and 500 by Maintenance DPP. Temperatures checked correctly with a new probe thermometer. During an observation on 04/23/24 12:35 PM, temperature checks were performed on showers and sinks on hall 200, 300, 400, and 500 by Maintenance DPP. Temperatures checked correctly with a new probe thermometer. During an observation on 04/23/24 at 1:35 PM, DPP performed water temperature checks using a new thermometer with a probe on Hall 100 sink and shower due to them being too low before. The sink reading was 104 degrees, and the shower reading was 104 degrees. During an interview with the ADMN, she stated the IDT team had not started focused partner rounds to address water temperatures during showers due to not being able to use showers until the immediate jeopardy was lowered. The ADMN provided the check sheet the facility intended to use once they began rounds. An Immediate Jeopardy was identified on 04/22/2024. While the Immediate Jeopardy was removed on 04/23/2024, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm and a scope of pattern, due to the facility monitoring the effectiveness of their Plan of Removal. The ADMN, DON, and RRN were informed of the Immediate Jeopardy was removed on 04/23/2024 at 3:10 p.m.

Based on interview and record review, the facility failed to ensure that residents had the right to choose their schedule for 2 of 6 residents (Residents #12 and #63) reviewed for self-determination preferences. The facility failed to allow Resident's #12 and #63 to smoke more than one cigarette while on their smoke break. This failure could place residents at risk of diminished feeling of self-worth, depression, and or diminished quality of life. Findings include: Resident #12 Record Review of Resident #12's Face Sheet dated 04/24/2024, revealed he was a [AGE] year-old Male, admitted to the facility on [DATE], with a Diagnoses of muscle weakness and wasting, difficulty walking, depression and tobacco use and heart disease. Resident #12's MDS, dated [DATE], Section C revealed a BIMS score of 11 (moderately impaired cognition). Resident #12's Care Plan dated 10/10/2023 revealed: Focus- The resident has coronary artery disease related to Hypertension, lifestyle choices, Smoking. Goal-The resident will be free from/sx (signs) of complications of cardiac problems through the review date. Interventions-Educate the resident/family/caregivers about: factors which might precipitate irregular heart rate: Alcohol, Caffeine, Stress, Activity. Encourage compliance to treatment regimen and follow up with physician. Encourage resident to refrain from smoking. Resident #12's smoking assessment dated [DATE] revealed, he can independently light smoking materials safely dispose of ashes and other tobacco-related residue appropriately. Resident #12 can also extinguish smoking materials completely in an appropriate receptacle. Resident #12 orders revealed no evidence of having only one cigarette during the 15-minute break. Interviews during a confidential meeting on 04/22/2024 at 10:02 AM, Resident #12 wanted to know if there were a policy that stated he can only have 1 cigarette during smoke breaks for himself and other smoking residents. During an interview on 04/24/24 at 11:23 AM, Resident # 12 voiced that he was upset that he was only allowed 1 cigarette per smoke break. He stated that he had smoked 2 packs prior to admission and does not feel that 1 cigarette was enough. He voiced that he would have no problem smoking 2-3 cigarettes in the 15 minutes that were allotted to him during the smoke breaks provided. Resident #63 Record Review of the resident #63's Face Sheet dated 04/25/2024, revealed he was a 63 yr. old male, admitted to the facility on [DATE], with a Diagnoses of Major Depressive Disorder, Anxiety Disorder, tobacco use and insomnia. Resident 63's MDS, dated [DATE], Section C revealed a BIMS score of 11 (moderately impaired). Resident #63's Care Plan dated 08/10/2023 revealed: Focus-The resident is a smoker. Goal-The resident will not smoke without supervision through the review date. Interventions-Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Observe clothing and skin for signs of cigarette burns. Resident #63's smoking assessment dated [DATE] revealed, he can independently light smoking materials safely and can the resident dispose of ashes and other tobacco-related residue appropriately. Resident #63's Orders revealed no evidence of having only one cigarette during the 15-minute break. During an interview on 04/23/24 at 11:30 AM, HK-J stated that she had worked there since 2021. She stated that she performed the smoke breaks on the days she worked approximately 3-4 days a week. She stated she took the resident's out to smoke on those days. She stated the rules were for residents to have only 1 cigarette during a 15-minute smoke break. HK-J stated she did not know what the policy was about smoking. She stated at one time they had a red box with a sign that had said, only one cigarette a break. During an interview on 04/25/2024 at 11:15 AM, the SW stated the residents were only allowed to have 1 cigarette per smoke break every three hours. She stated there were two safe smokers that had been given smoke breaks at night due to these two residents only able to have one cigarette throughout the day with each smoke break. The SW stated in doing that, it had helped them sleep but inconvenient for them as it was at 12:30 AM and 3:30 AM. She stated even at those times, Resident #12 and Resident #63 were still to only have one cigarette. The SW stated the rules were in the corporate facility policy. She stated the department heads had a meeting with the smokers about what the violations would be if they did not adhere to those rules. The SW stated she was unaware the facility policy showed no evidence that the residents could only have one cigarette. She stated she had previously been told that it was the way it had always been done the past three years. The SW stated the residents received $60 a month and stated that was another reason they ration the residents cigarettes. During an interview on 04/25/2024 at 11:35 AM, the ADMN stated there was a limit to only one cigarette while the residents were out on smoke break. She stated it was corporate policy and the Department Heads (ADMN, DON, and AD), had a smoking RC meeting as well, to let the residents know what the rules were. The ADMN stated the residents were told that if they violated the smoking policy, they would get written up with a smoking violation. The ADMN stated it was the Department Heads that had that specific RC so they (Dept. Heads and smoking Residents) would be on the same page. She stated once having read the smoking policy at that time, there was no mention of residents only could have one cigarette per smoke break. She stated the Department Heads had decided it kept the residents on their budget as well as not having residents stealing cigarettes from other residents who smoked. The ADMN stated it would also prevent them from running out of money at the end of each month. She stated, it was not fair to the residents, but it kept them on the same level and in reality, it was not fair, but the one cigarette is in all fairness to all who smoke. The ADMN stated she made the determination across the board with that being the best for the community. She stated she thought it was fair to make a blanket rule. She stated if someone asked her if they could have another cigarette with plenty of time left in that smoke break, she would have always told them No because it was based on the situational needs of all residents. She stated the failure was that the residents did not like to be monitored and was the reason that certain residents had brought it up. The ADMN stated she thought the negative impact were the residents health if they smoke more than one. The ADMN stated her expectations were for the residents on only have one cigarette per break. She stated that ultimately it was her decision. During an interview on 04/25/2024 at 2:34 PM, the RRN stated she was unaware the residents were being told they could only smoke 1 cigarette. She stated it was not in their facility policy that the residents could only have 1 cigarette during their 15-minute scheduled smoking times. She stated they had the right to smoke as many as they wanted if it were during that scheduled time. Review of facility Resident Smoking Council Meeting Minutes, dated 02/16/2024 revealed no evidence of advising residents they could have only one cigarette during their 15-minute break. Review of facility's policy titled Risk Management, Smoking Policy, dated 06/11/2018 revealed .Standard of Practice Explanation and Compliance Guidelines Self Determination the Resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice, including but not limited to a. The resident has a right to choose activities, schedules (including sleeping and waking times) . The facility policy showed no evidence the residents could have only one cigarette during their 15-minute smoke break. Review of facility's policy titled Resident Rights, dated 08/2009 revealed; Policy Statement: Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1.k. Retain and use personal possessions to the maximum extent that space and safety permit; 2. Residents are entitled to exercise their rights and privileges to the fullest extent possible. 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness, and dignity 48883

48883 Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike environment for 3 of 17 (Resident #4, #22, and #32) resident rooms reviewed for resident rights. 1. The facility failed to ensure the hot water faucet worked in Resident #4's and #22's rooms. 2. The facility failed to ensure hot water in room was above 100? in Resident #32's room sink. 3.The facility failed to ensure hand washing sink drained water without resident holding up drain with hand by reaching into used water in Resident #32's room. 4. The facility failed to ensure closets had doors that would enclose resident's clothing. These failures could place residents at risk for infection and diminished clean, homelike environment. Findings included: Resident #4 Record review of Resident #4's face sheet dated 04/24/2024 revealed he was a [AGE] year-old male admitted to the facility on [DATE], with a diagnosis of chronic obstructive pulmonary disease (lung disease interfering with airflow), dementia, major depressive disorder, anxiety, tobacco use, diabetes, and acquired absence of right and left leg (leg amputations). Record Review of Resident #4's quarterly MDS assessment dated [DATE], Section C - Cognitive Patterns revealed a BIMS score of 09 (moderate cognitive impairment); Section GG- Functional Abilities and Goals revealed resident needed setup or cleanup assistance with eating, needed supervision with oral hygiene, toilet hygiene, upper body dressing, lower body dressing, and personal hygiene, and needed partial assistance with bathing. During an observation and interview on 04/21/2024 at 3:53 p.m., the sink in Resident #4's room, hot water faucet, would not turn on and left closet door not present leaving resident's clothing exposed. Resident #4 stated that he would like to have warm or hot water available in his room. He voiced he washed his hands and face with the water from sink. He stated that he had told staff his hot water did not work, and nothing had been done about it. Resident #22 Record review of Resident #22's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of seizures, diabetes, morbid obesity, muscle weakness, and lack of coordination. Record review of Resident #22's admission MDS dated [DATE] Section C - Cognitive Patters revealed a BIMS score of 12 (moderate cognitive impairment); Section GG- Functional abilities and Goals revealed resident needed setup or cleanup assistance with eating and oral hygiene, needed supervision with upper body dressing, and needed partial assistance with toileting hygiene, bathing, lower body dressing, putting on or taking off footwear and personal hygiene. During an observation and interview on 04/24/2024 at 12:19 p.m., the sink in Resident #22's room only had cold water. Resident #22 stated she would like to have warm or hot water in her room and had not had it since she moved into the facility. Resident #32 Record review of Resident #32's face sheet dated 04/24/2024 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of encephalopathy (damage or disease that effects the brain), dementia, unsteadiness of feet, hypertension (high blood pressure), and lack of coordination. Record review of Resident #32's quarterly MDS dated [DATE], Section C revealed a BIMS score of 10 (moderate cognitive impairment); Section GG- Functional abilities and Goals revealed resident needed setup assistance with eating, supervision with bathing, and was independent with oral hygiene, toileting hygiene, upper body dressing, lower body dressing, putting on and taking off footwear, and personal hygiene. During an observation and interview on 04/21/2024 at 10:48 a.m., the sink in Resident #32's room would not drain water without resident putting hand down in used water and holding up the drain plug. Hot water temperature obtained with thermometer, read 92.4 ?. Resident stated that she did not mind water not being hot. She stated she was not sure how long the drain had not functioned without her holding the plug up. Record review of resident council minutes from January and February of 2024 revealed concerns with hot water on 500 hall. Record review of maintenance log on 04/21/2024 revealed no evidence that 500 hall's hot water concerns were addressed or that Resident #32's drain not draining. During an interview on 04/23/2024 at 10:39 a.m., AD stated she was who made notes in the resident council minutes. She stated hot water concern on 500 hall meant some sinks did not have hot enough water or no hot water at all. During an observation on 04/24/2024 at 3:33 p.m., room [ROOM NUMBER] right closet door missing leaving resident's clothing exposed. During an observation on 04/24/2024 at 12:19 p.m., room [ROOM NUMBER] had only cold water available in the only sink in the room and closet doors leaving resident's clothing exposed. During an observation on 04/21/2024 at 11:45 a.m., room [ROOM NUMBER] had left closet door sitting on floor on A side of room and lying against the wall. Left closet clothing left exposed. During a follow up interview on 04/25/2024 at 8:33 a.m., the AD stated when a concern was brought up in resident council then she would take the concern to the responsible department head for that concern. She stated DPP would be notified if there were issues with maintenance such as plumbing. She stated that she was unsure if the current DPP worked in January or February of 2024 and was unsure who concern was brought up to during that time. She stated the facility discussed concerns during their scheduled QAPI meetings also. She was not able to state whether the hot water concern was corrected. During an interview on 04/25/2024 at 8:38 a.m., the ADMN stated it was her expectation that resident rooms had working water. She did not voice any negative outcome to residents when faucets and drains were not in working order. She would not state her expectation about closet doors adding that some people would not mind having no closet doors. She did not voice any negative outcome to residents. She stated DPP was responsible for monitoring that items in the room were working. ADMN stated verbal discussions were made when items needed to be fixed. She did not provide any evidence that verbal communication had occurred. During an interview on 04/25/2024 at 10:20 a.m., the DPP stated he had ordered parts to fix hot water faucets in the sinks that he knew were not working. He stated it was hard to obtain parts due to facility's location and no stores close by, so he had to have parts shipped. He stated that he did not have computer access to order supplies until two to three weeks ago which delayed his ability to correct issues. He stated he had been attempting to find [NAME] brackets to fix closet doors, but they were no longer available to order. He stated he had been verbally told about some items not working but felt that he forgot some of the items that were told to him when he became busy during his workday. Review of facility's policy titled Maintenance Service dated December 2009 revealed: The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times .Functions of maintenance personnel include but are not limited to .maintaining the heat/cooling system, plumbing fixtures, wiring, etc., in good working order. Review of facility's policy titled Work Orders, Maintenance revised in April 2010 revealed: Maintenance work orders shall be completed in order to establish a priority of maintenance service .In order to establish a priority of maintenance service, work orders must be filled out and forwarded to the Maintenance Director .It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director .A supply of work orders is maintained at each nurses' station .Work order requests should be placed in the appropriate file basket at the nurses' station. Work orders are picked up daily .Emergency requests will be given priority in making necessary repairs. Review of facility's policy titled Quality of Life - Homelike Environment revised in May 2017 revealed: Staff shall provide person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences .The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include Clean, sanitary and orderly environment.

Based on observations, interviews, and record reviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections for residents who are incontinent of bladder, for 2 of 18 (Resident #17 and Resident #38) residents reviewed for incontinent care. The facility failed to ensure no cross-contamination occurred when CNA B failed to wash hands prior to, during, or after performing peri-care and failed to follow peri-care standards of practice when wiping in a zig-zag motion instead of front to back and when going from dirty to clean for Resident #17. The facility failed to ensure no cross-contamination occurred when CNA C failed to wash hands prior to, during, or after performing peri-care and failed to follow peri-care standards of practice when wiping in a zig-zag motion instead of front to back and when going from dirty to clean for Resident #38. These failures could place residents at risk of development and transmission of communicable diseases and infections. Findings included: Resident #17 Review of Resident #17's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: major depression, dementia, and psychotic disorder. Record review of Resident #17's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 05 which indicated severe cognitive impairment. Further review of the MDS Section GG Self-Care revealed toileting hygiene of substantial/maximal assistance. Further review of the MDS Section H Bladder and bowel revealed frequently incontinent of bladder and always incontinent of bowel. Record review of Resident #17's Care plan revised on 10/17/2023 revealed: Focus: The resident has mixed bladder incontinence and is at risk for skin breakdown r/t incontinence of urine r/t Dementia, Impaired Mobility. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. The resident's risk for septicemia will be minimized/prevented via prompt recognition and treatment of symptoms of UTI through the review date. Interventions: Clean peri-area with each incontinence episode. Establish voiding patterns. Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Resident #38 Review of Resident #38's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: dementia, pain, Alzheimer's, and fatigue. Record review of Resident #38's Significant Change MDS dated [DATE] revealed: BIMS not completed. Further review of the MDS Section GG Self-Care revealed toileting hygiene of dependent. Further review of the MDS Section H Bladder and Bowel revealed always incontinent of bowel and bladder. Record review of Resident #38's Care plan revised on 02/05/20 revealed: Focus: The resident has bladder incontinence and is at risk for skin breakdown r/t incontinence of urine dx of Alzheimer's. Goal: The resident will remain free from skin breakdown due to incontinence and brief use through the review date. Interventions: Clean peri-area with each incontinence episode. Encourage fluids during the day to promote prompted voiding responses. Ensure the resident has unobstructed path to the bathroom. Establish voiding patterns. Limit fluids 2-3 hours prior to bedtime. Monitor and document intake and output as per facility policy. During observation on 04/21/24 at 11:31 AM, CNA B performed peri-care on Resident #38 with the assist of CNA C. CNA B did not wash her hands prior to beginning. CNA B wiped perineal area in a zig-zag motion with one wipe. CNA B did not separate the labia and clean that area. CNA B did not change gloves or sanitize between removing dirty brief and applying clean brief. CNA B finished peri-care, removed gloves, and did not wash hands. CNA C assisted with turning of resident. CNA C then performed peri-care on Resident #17 with the assist of CNA B for turning. Neither CNA C nor CNA B washed their hands. CNA C wiped perineal area in a zig-zag motion with one wipe. CNA C did not separate the labia and clean that area. CNA C did not change gloves or sanitize between removing dirty brief and applying clean brief. CNA C finished peri-care, removed gloves, and did not wash hands. During an interview on 04/21/24 at 1:15 pm, CNA C stated she should have washed her hands prior to peri-care and after peri-care. She stated she was just nervous. CNA C stated she did not know she should have changed gloves between dirty and clean. She stated she had not been trained or checked off on peri-care since she had worked at the facility. During an interview on 04/21/24 at 1:30 pm, CNA B stated she did not wash her hands because the resident bathrooms were either too full to get into or they do not have hot water. She stated she felt that she cleaned the resident thoroughly. CNA B stated she had not performed any skills competencies. Record review of personnel files showed no evidence of skill competency checkoffs or peri-care training for CNA B hired on 12/12/2023. Record review of personnel files showed no evidence of skill competency checkoffs or peri-care training for CNA C hired on 01/13/2020. During an interview on 04/25/24 at 2:00 PM, the DON stated hands should be washed before, during, and after peri-care. She stated the perineal should be cleaned from front to back not a zig-zag motion and a new wipe should be used after each swipe. DON stated the labia should be separated and cleaned thoroughly. The DON stated she had not performed any staff competencies since she had been DON starting in February 2024. She stated she had called the previous DON to see if she had record of competencies but at that time, she had no record of when competencies were last performed. She stated she did not know how often staff performance should be evaluated or anything about their required annual training. Review of facility's policy titled Perineal Care not dated revealed: Steps in Procedure: .2. Wash and dry your hands thoroughly .6. Put on gloves 8. For a female resident a. use wipes and apply skin cleansing agent. B. wash perineal area, wiping from front to back. 1. Separate labia and wash area downward from front to back. (Note: If the resident has an indwelling catheter, gently wash the juncture of the tubing from the urethra.

Based on observation, interview, and record review, the facility failed to attempt to use alternatives prior to installing a side or bed rail and assess the resident for risk of entrapment from bed rails prior to installation for 3 of 3 residents (Resident #26, Resident #59, and Resident #68) reviewed for bed rails. 1. The facility failed to assess residents for entrapment risks and attempt less restrictive measures prior to installing bed rails. 2. The facility failed to obtain informed consent prior to installation of bed rails. These failures could place residents at risk for injury and restricted movement. The findings include: Resident #26 Record review of Resident #26's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's, dementia, and depression. Record review of Resident #26's quarterly MDS assessment dated [DATE] revealed: BIMS score of 06 which indicated severe cognitive impairment. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used and Section GG- Functional Abilities and Goals revealed resident needed partial assistance with rolling left and right in the bed, ability to move from sitting to lying, ability to move from lying on the back to sitting on the side of the bed, and ability to move from bed to chair. Record review of Resident #26's care plan initiated on 03/07/2024 revealed no evidence of side rails. Record review of Resident #26's electronic physicians Orders revealed no evidence of order for side rails. Record review of Resident #26's electronic medical record revealed no evidence that risk for entrapment was performed, less restrictive measures were attempted, or informed consent was obtained prior to installation of bed rails. During an observation on 04/25/24 at 1:53 p.m., Resident #26 was resting in bed with bilateral half side rails up. Resident was not able to be interviewed or answer questions. Resident #59 Record review of Resident #59's electronic face sheet dated 04/24/2024 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: major depressive disorder, dementia, insomnia, muscle weakness, psychotic disorder with delusions, and anxiety. Record review of Resident #59's quarterly MDS dated [DATE] revealed: BIMS score of 02 which indicated severe cognitive impairment. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used and Section GG- Functional Abilities and Goals revealed resident needed substantial assistance to roll left and right in the bed, and helped does all of the effort with ability to move from sitting to lying, ability to move from lying on the back to sitting on the side of the bed, and ability to move from bed to chair. Record review of Resident #59's Care plan initiated on 01/04/2024 revealed: Focus: Resident requires the use of 1/2 side rails to assist with bed mobility. Goal: Dignity will be maintained, and no occurrence of injury will occur throughout the review date. Interventions: Evaluate and Re-evaluate for 1/2 side rail use quarterly and PRN. Explain reason and risks of 1/2 side rails using terms the resident and responsible party can understand. Monitor for proper positioning and circulatory concerns report any significant changes to MD promptly. Record review of Resident #59's electronic physicians orders revealed no evidence of an order for side rails. Record review of Resident #59's electronic medical record revealed no evidence that risk for entrapment was performed, less restrictive measures were attempted, or informed consent was obtained prior to installation of bed rails. During an observation on 04/21/2024 at 11:15 a.m., Resident #59 was sitting in the dining area of the secured unit. Resident 59's room [ROOM NUMBER]-A had bilateral half side rails present and the left side was in the up position. Attempted phone interview on 04/21/2024 at 6:20 p.m. with Resident #59's responsible party who refused interview at this time. Resident #68 Review of Resident #68's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: blindness, depression, autistic disorder, and Down's syndrome. Record review of Resident #68's admission MDS dated [DATE] revealed: BIMS not completed that indicated resident was unable to complete related to resident is rarely or never understood. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used, and Section GG- Functional Abilities and Goals revealed partial assistance needed for resident to roll left and right in the bed and ability to move from sitting to lying and needed substantial assistance with ability to move from lying on the back to sitting on the side of the bed, and ability to move from bed to chair. Record review of Resident #68's Care plan initiated on 03/04/2024 revealed: Focus: Resident requires the use of 1/2 side rails to assist with bed mobility. Goal: Dignity will be maintained, and no occurrence of injury will occur throughout the review date. Interventions: Evaluate and Re-evaluate for 1/2 side rail use quarterly and PRN. Explain reason and risks of 1/2 side rails using terms the resident and responsible party can understand. Monitor for proper positioning and circulatory concerns report any significant changes to MD promptly. Record review of Resident #68's electronic physicians orders revealed: MAY USE SIDE RAILS FOR POSITIONING, dated 03/04/2024. Record review of Resident #68's electronic medical record revealed no evidence that risk for entrapment was performed, less restrictive measures were attempted, or informed consent was obtained prior to installation of bed rails. During an observation on 04/25/2024 at 01:59 p.m. Resident #68 was lying in bed with bilateral half rails in the up position. Resident unable to be interviewed or answer questions. During an interview on 04/25/2024 at 12:03 p.m., LVN I stated the facility did not use bed rails to keep residents in their beds but used them as mobility aides. She stated that a consent should be obtained, and a physician's order was needed prior to bed rails being installed. She stated that she would perform a mobility device assessment in the electronic medical record when a resident had bed rails and would know to perform when UDA (un-documented assessments) triggered. She was unsure who scheduled out the assessment on the UDA. LVN I stated the effect of placing bed rails on a resident's bed that did not have orders, consent, or appropriate assessment could cause resident to potentially fall or get caught in the rail. During an interview on 04/25/2024 at 12:05 p.m., CNA F stated the facility did not use bed rails to keep residents in their beds but for mobility. She stated that Resident #59 had recently moved into room [ROOM NUMBER] and felt that the bed may have had rail prior to her being in the room. During an observation and interview on 04/25/2024 at 1:10 p.m., Resident #59's bed had bilateral half rails with left rail (closest to the wall) in the up position. The ADON stated that facility did not use bed rails to keep residents in their beds. She stated that she did not know the facility's policy on bed rails. During an interview on 04/25/2024 at 1:15 p.m., the DON stated her expectation would be for physician orders to be obtained and consent obtained prior to installing bed rails on a resident's bed. She felt that the failure had occurred due to Resident #59 had recently changed rooms and bed rails being present prior to room change. She stated that she and the RRN were responsible for monitoring that proper items were in place prior to bed rails being installed on the beds. She was not aware of any assessment that needed to be performed for bed rails. She stated that the effect to the resident could be having an injury from a fall. During an interview on 04/25/2024 at 1:18 p.m., the RRN stated she expected for a physician's order, informed consent, an entrapment risk assessment, and an assessment of bed to make sure bed rail fit properly prior to bed rails being used. She stated that both her and the DON were responsible to make sure those tasks were performed. During a follow up interview on 04/25/2024 at 1:37 p.m., the DON stated the assessment that should have been performed was titled Bed Rail Entrapment Assessment and the DPP should have been performing. She stated that the DPP would be in-serviced then he could start to perform assessments. Review of facility's policy titled Bed Safety dated 04/2021 revealed: Focused Communities will strive to provide a safe sleeping environment for the resident. Procedure 1. The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement, as well as input from resident and family regarding previous sleeping habits and bed environment. 2. To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard, and bed accessories), the facility shall promote the following approaches: a. An inspection should be done by the Director of Plant Operations at installation/before use and quarterly thereafter of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, movement, or bed position. c. Ensure that when bed system components are worn and need to be replaced, they are replaced with compatible components that meet manufacturer's specifications; d. Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and e. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.). 3. The Director of Plant Operations shall provide a copy of inspections to the Executive Director of Operations and report results to the QA Committee recommendations shall be maintained by the Executive Director of Operations and/or Safety Committee. 4. The facility's education and training activities will include instruction about risk factors for resident injury due to beds, and strategies for reducing risk factors for injury, including entrapment. 5. If side rails are used, there shall be an interdisciplinary assessment of the resident, consultation with the Attending Physician, and input from the resident and/or legal representative. 6. The staff shall obtain consent for the use of side rails from the resident or the resident's legal representative prior to their use. 7. After appropriate review and consent as specified above, side rails may be used at the resident's request to increase the resident's sense of security (e.g., if he/she has a fear of falling, his/her movement is compromised, or he/she is used to sleeping in a larger bed). 8. Side rails may be used if assessment and consultation with the Attending Physician has determined that they are needed to help manage a medical symptom or condition, or to help the resident reposition or move in bed and transfer, and no other reasonable alternatives can be identified. 9. Before using side rails for any reason, the staff shall inform the resident and family about the benefits and potential hazards associated with side rails. 10. When using side rails for any reason, the staff shall take measures to reduce related risks. 11. Side rails shall not be used as protective restraints. Should a protective restraint be used, communities' protocol for the use of restraints shall be followed. 12. The use of physical restraints on individuals in bed shall be limited to situations where they are needed to treat a resident's medical symptoms, and only after being reviewed by authorized individuals. 13. The staff shall report to the Director of Clinical Operations and Executive Director of Operations any deaths, serious illnesses and/or injuries resulting from a problem associated with a bed and related equipment including the bed frame, bed side rails, and mattresses. The Executive Director of Operations shall ensure that reports are made to the Food and Drug Administration or other appropriate agencies, in accordance with pertinent laws and regulations including the Safe Medical Device Act. 48883

Based on interview and record review, the facility failed to review the work of each Certified Nurse Aid (CNA) every 12 months for 4 (CNA-D, CNA-E, CNA-F and CNA G) of 5 CNAs reviewed for nursing services. The facility failed to provide CNA competency evaluations at least every 12 months after hire. This failure could result in inadequate CNA performance while providing care for residents. Findings include: Record Review of Personnel Files revealed: - Employee record for CNA-D revealed a hire date of 10/04/2021 and had no evidence of a competency evaluation at least every 12 months after hire. - Employee record for CNA-E revealed a hire date of 10/19/2021 and had no evidence of a competency evaluation at least every 12 months after hire. - Employee record for CNA-F revealed a hire date of 11/15/2021 and had no evidence of a competency evaluation at least every 12 months after hire. - Employee record for CNA-G revealed a hire date of 10/14/2021 and had no evidence of a competency evaluation at least every 12 months after hire. During an interview on 04/25/2024 at 2:00 PM, the DON stated she had not performed any staff competencies since she had been hired as DON, February 2024. She stated she had called the previous DON to see if she had the records of CNA competencies, but she had no records. She stated she did not know how often staff performances should have been evaluated or their required annual training. The DON stated she was supposed to have monitored the CNA competency trainings. She stated the negative impact to residents could have been them not performing their duties correctly and possibly not giving them the proper care they deserved. She stated the failure was that she had not followed up with making sure the CNA's had all been trained correctly with documentation. The DON stated her expectations were for them to have had all of the competencies they needed and have the proper training and to take care of the residents as required. Record Review of the facility's policy titled Nurse Aide Education, dated 08/16/17, revealed the following: - Competency will be evaluated initially and annually. - Facility will conduct a performance review of each nurse aide at least once every 12 months. 45732

Based on observation, interview, and record review, the facility failed to ensure residents with PRN orders for psychotropic drugs were limited to 14 days for 6 (Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, and Resident #52) of 11 residents reviewed for pharmacy services. The facility failed to ensure Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, and Resident #52 had stop dates for PRN Lorazepam (medicine used to treat the symptoms of anxiety). This failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications. Resident #45 Review of Resident #45's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, depression, dementia, and Alzheimer's. Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 04 which indicated severe cognitive impairment. Further review of the MDS Section N Medications revealed antianxiety medications taken in the last 7 days during the look back period (assessment period). Record review of Resident #45's Care plan revised on 10/24/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Monitor/record occurrence of for target behavior symptoms (SPECIFY pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others. etc.) and document per facility protocol. Record review of Resident #45's electronic Physicians Orders revealed: Lorazepam Concentrate 2 MG/ML Give 0.5 ml sublingually every 4 hours as needed for restlessness/agitation/anxiety, dated 02/11/2022 with no stop date. Record review of Resident #45's MAR, dated April 2024, revealed no evidence of Lorazepam being administered. Review of Resident #45's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #10 Review of Resident #10's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: bipolar disorder, difficulty swallowing, and anxiety. Record review of Resident #10's Significant Change MDS dated [DATE] revealed: BIMS score not completed. Further review of the MDS Section N Medications revealed antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #10's Care plan revised on 10/17/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #10's electronic Physicians Orders revealed: Lorazepam Intensol Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation/anxiety, dated 02/06/2024 with no stop date. Record review of Resident #10's MAR, dated April 2024, revealed Lorazepam was administered on 04/23/24 at 11:53 am and 04/24/24 at 11:49 am. Review of Resident #10's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #18 Review of Resident #18's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: paralysis, diabetes, irregular heartbeat, and difficulty swallowing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed: BIMS score 00 which indicated severe cognitive impairment. Further review of the MDS Section N Medications revealed antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #18's Care plan revised on 12/20/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #18's electronic Physicians Orders revealed: Lorazepam Injection Solution 2 MG/ML (Lorazepam) Give 0.5 ml sublingually every 4 hours as needed for restlessness/agitation/anxiety, dated 12/29/2023 with no stop date. Record review of Resident #18's MAR, dated April 2024, revealed no Lorazepam had been administered. Review of Resident #18's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #58 Review of Resident #58's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: diabetes, liver failure, and high blood pressure. Record review of Resident #58's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medications taken in the last 7 days during the look back period (assessment period). Record review of Resident #58's Care plan revised on 12/20/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #58's electronic Physicians Orders revealed: Lorazepam Solution 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation/anxiety, dated 12/15/2022 with no stop date. Record review of Resident #58's MAR, dated April 2024, revealed no Lorazepam had been administered. Review of Resident #58's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, brain bleed, and Parkinson's disease. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section N Medications revealed no antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #2's Care plan revised on 12/20/2023 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #2's electronic Physicians Orders revealed: Lorazepam Solution 2 MG/ML (Lorazepam) Give 0.5 ml by mouth every 4 hours as needed for restlessness/agitation/anxiety, dated 12/15/2022 with no stop date. Record review of Resident #2's MAR, dated April 2024, revealed no Lorazepam had been administered. Review of Resident #2's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. Resident #52 Review of Resident #52's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: prostate cancer, anxiety, and respiratory failure. Record review of Resident #52's Admission MDS dated [DATE] revealed: BIMS score 08 which indicated moderate cognitive impairment. Further review of the MDS Section N Medications revealed antianxiety medication taken in the last 7 days during the look back period (assessment period). Record review of Resident #52's Care plan revised on 03/22/2024 revealed: Focus: The resident uses antianxiety Medication. Goal: The resident will be free from discomfort or adverse reactions related to anti-anxiety therapy through the review date. Interventions: Administer ANTI-ANXIETY medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. Monitor/document/report PRN any adverse reactions to ANTI-ANXIETY therapy: Drowsiness, lack of energy, clumsiness, slow reflexes, Slurred speech, confusion and disorientation, depression, dizziness, lightheadedness, impaired thinking and judgment, memory loss, forgetfulness, nausea, stomach upset, blurred or double vision. UNEXPECTED SIDE EFFECTS: Mania, hostility, rage, aggressive or impulsive behavior, hallucinations. Record review of Resident #52's electronic Physicians Orders revealed: Lorazepam Intensol Oral Concentrate 2 MG/ML Give 0.5 ml by mouth every 1 hours as needed for Anxiety/Agitation/Restless, ordered 03/22/2024 with no stop date. Record review of Resident #52's MAR, dated April 2024, revealed: lorazepam was administered on 04/21/2024 at 2:59 am and 6:48 am, 04/23/2023 at 1:00 pm and 2:42 pm, and 04/24/2024 at 4:12 am, 10:10 am, 11:53 am, and 7:14 pm. Review of Resident #52's physician progress notes from January 2024- April 2024 revealed no documented rationale for the continued provision of lorazepam. During an interview on 04/24/2024 at 10:45 AM, the DON stated she was aware of the regulation on PRN psychotropic medications. She stated it was her responsibility to monitor and ensure all PRN psychotropic medications had a stop date no longer than 14 days. The DON stated she had been the DON since February and had been very busy and she just missed the orders. She stated she did not know the possible negative outcome other than not following the regulation. Review of facility policy titled, Psychotropic Medication Review not dated revealed: Policy: IDT will emphasize the importance of seeking an appropriate dose and duration of each psychotropic medication, with careful assessment as to whether the medication is necessary and pharmacologically appropriate. Standards: 1. The community will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications, to include regular review for continued need, appropriate dosage, side effects, risks and/or benefits. 2. The community supports the appropriate use of psychopharmacologic medications that are therapeutic and enabling for residents suffering from mental illness. 3. The community supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of environmental, mental, and/or behavioral interventions, as well as psychopharmacological medications can be utilized to meet the needs of the individual resident. 4. Efforts to reduce dosage or discontinue of psychopharmacological medications will be ongoing, as appropriate, for the clinical situation. 5. Psychopharmacological medications will never be used for purpose of discipline or convenience. Procedures: 1. Monitors psychotropic drug use noting any adverse effects. 2. Reviews of the use of the medications with IDT on monthly basis, during Standard of Care Meeting to determine the continued presence of target behaviors and or the presence of any adverse effects of the medications. 3. Monitors psychotropic drug use to ensure that medications are not used in excessive doses or for excessive duration. 4. Monitor psychotropic drug use for gradual dose reduction (GDR) potential. 5. Monitor GDR for success or failure, related to targeted behaviors. Review of Drugs.com for Lorazepam accessed on 04/29/2024 at https://www.drugs.com/lorazepam.html revealed: Lorazepam belongs to a class of medications called benzodiazepines. It is thought that benzodiazepines work by enhancing the activity of certain neurotransmitters in the brain. Lorazepam is used in adults and children at least [AGE] years old to treat anxiety disorders. 48883

Based on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services in that: The facility failed to ensure the dry food storage was not past their use by dates. This failure placed residents at risk for food borne illnesses. Findings include: During an observation on [DATE] at 9:45 AM, the dry storage pantry revealed: 1. 6 packages of 16 oz. sealed marshmallows in the original packaging with an use by date of [DATE]. 2. 1 opened box of shredded coconut with the in date of [DATE] and an opened date of [DATE]. 3. 1 sealed 20 lb. box of black-eyed peas with an use by date of [DATE]. During an interview on [DATE] at 10:44 AM, the DM stated there should have been no expired food in the pantry. She stated the product dates should have been checked on a weekly basis as well as when the truck came in with products. She stated she had previously given in-services for food safety to her kitchen staff on [DATE]. She stated she should have monitored the stored food as well as what came in on the trucks to the kitchen more closely. The DM stated the failure occurred with the kitchen department head and having not paid attention to the expired products and dates. She stated the negative impact was it could have possibly made residents sick, and her expectations would have been that all products were checked correctly daily. During an interview on [DATE] at 11:45 AM, the ADMN stated the expiration dates on food products should have been checked every day and updated weekly as well as rotating food products. She stated she would only go into the kitchen when she needed to. She stated she the DM monitored products to make sure there were no outdated products, but that ultimately the ADMN monitored the DM. The ADMN stated the negative impact to residents were that they could get sick. She stated the failure occurred with the chain of command with trainings not being adhered to. She stated her expectations were that the products be labeled and dated as they come in off the truck and rotating and using the oldest dated products before their expired date. Record review of facility's food manager training, Food Safety Articles, First In, First Out (FIFO), undated, revealed; FIFO organizes food by expiration or use-by date Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed [DATE] revealed: ,d+[DATE].11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (2) If made from two or more ingredients, a list of ingredients and sub-ingredients in descending order of predominance by weight, including a declaration of artificial colors, artificial flavors and chemical preservatives, if contained in the FOOD; (3) An accurate declaration of the net quantity of contents; (4) The name and place of business of the manufacturer, [NAME], or distributor; and (5) The name of the FOOD source for each MAJOR FOOD ALLERGEN contained in the FOOD unless the FOOD source is already part of the common or usual name of the respective ingredient. Pf (6) Except as exempted in the Federal Food, Drug, and Cosmetic Act S 403(q)(3) - (5), nutrition labeling as specified in 21 CFR 101 - Food Labeling and 9 CFR 317 Subpart B Nutrition Labeling. (7) For any salmonid FISH containing canthaxanthin or astaxanthin as a COLOR ADDITIVE, the labeling of the bulk FISH container, including a list of ingredients, displayed on the retail container or by other written means, such as a counter card, that discloses the use of canthaxanthin or astaxanthin.

45732 Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 11 (Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34) of 11 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness to ensure Resident #45, Resident #10, Resident #18, Resident #58, Resident #2, Resident #52, Resident #26, Resident #19, Resident #21, Resident #35, and Resident #34 received adequate end-of-life care. The facility failed to have physicians' orders for Hospice Care for Resident #10, Resident #58, Resident #2, Resident #52, Resident #21, and Resident #35. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs. The findings included: Resident #45 Review of Resident #45's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, diabetes, depression, dementia, and Alzheimer's. Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed: BIMS score of 04 which indicated severe cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #45's Care plan revised on 09/01/2023 revealed: Focus: The resident has a terminal prognosis r/t Alzheimer's Disease. On Hospice Services. Goal: The resident's comfort will be maintained through the review date. Interventions: Assess resident coping strategies and respect resident wishes. Consult with physician and Social Services to have Hospice care for resident in the facility. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Encourage support system of family and friends. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Record review of Resident #45's electronic Physicians Orders revealed: Admit to Hospice, dated 02/11/2022. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #45. Resident #10 Review of Resident #10's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: bipolar disorder, difficulty swallowing, and anxiety. Record review of Resident #10's Significant Change MDS dated [DATE] revealed: BIMS score not completed. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #10's Care plan revised on 02/07/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Huntington's. On hospice Services. Goal: The resident's dignity and autonomy will be maintained at highest level through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #10's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #10. Resident #18 Review of Resident #18's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: paralysis, diabetes, irregular heartbeat, and difficulty swallowing. Record review of Resident #18's Quarterly MDS dated [DATE] revealed: BIMS score 00 which indicated severe cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #18's Care plan revised on 12/20/2023 revealed: Focus: The resident has a terminal prognosis HEMIPLEGIA AND HEMIPARESIS FOLLOWING CEREBRAL INFARCTION AFFECTING RIGHT DOMINANT SIDE. On Hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: May oral suction PRN. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #18's electronic Physicians Orders revealed: Admit to Hospice ., dated 12/29/23. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #18. Resident #58 Review of Resident #58's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: diabetes, liver failure, and high blood pressure. Record review of Resident #58's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #58's Care plan revised on 09/29/2023 revealed: Focus: The resident has a terminal prognosis r/t liver failure. HOSPICE. Goal: The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Assess resident coping strategies and respect resident wishes. Consult with physician and Social Services to have Hospice care for resident in the facility. Encourage support system of family and friends. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review resident's living will and ensure it is followed. Involve family in discussion. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #58's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #58. Resident #2 Review of Resident #2's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: depression, anxiety, brain bleed, and Parkinson's disease. Record review of Resident #2's Quarterly MDS dated [DATE] revealed: BIMS score 10 which indicated moderate cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #2's Care plan revised on 09/29/2023 revealed: Focus: The resident has a terminal prognosis r/t liver failure. HOSPICE. Goal: The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Assess resident coping strategies and respect resident wishes. Consult with physician and Social Services to have Hospice care for resident in the facility. Encourage support system of family and friends. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Review resident's living will and ensure it is followed. Involve family in discussion. Work with nursing staff to provide maximum comfort for the resident. Record review of Resident #2's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #2. Resident #52 Review of Resident #52's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: prostate cancer, anxiety, and respiratory failure. Record review of Resident #52's Admission MDS dated [DATE] revealed: BIMS score 08 which indicated moderate cognitive impairment. Further review of the MDS Section O Special Treatments, Procedures, and Programs revealed Hospice Care. Record review of Resident #52's Care plan revised on 03/22/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: C61 Malignant neoplasm of prostate. On Hospice Services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #52's electronic Physicians Orders revealed no evidence of an order for Hospice Care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #52. Resident #26 Review of Resident #26's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's, dementia, and depression. Record review of Resident #26's Quarterly MDS dated [DATE] revealed: BIMS score 06 which indicated severe cognitive impairment. Further review of the MDS Section P Restraints and Alarms revealed no bed rails used. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #26's Care plan initiated on 03/07/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Alzheimer's. On hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Assess resident coping strategies and respect resident wishes. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Record review of Resident #26's electronic Physicians Orders revealed: May admit to hospice ., dated 03/07/24. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #26. Resident #19 Review of Resident #19's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: pneumonia, diabetes, and dementia. Record review of Resident #19's Quarterly MDS dated [DATE] revealed: BIMS score not completed. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #19's Care plan revised on 03/28/2024 revealed: Focus: The resident has a terminal prognosis r/t DYSPHAGIA FOLLOWING CEREBRAL INFARCTION. On hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Encourage support system of family and friends. Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Suction as needed due to excess secretions. Record review of Resident #19's electronic Physicians Orders revealed: May admit to hospice ., dated 11/21/23. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #19. Resident #21 Review of Resident #21's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: anxiety, dementia, and bipolar disorder. Record review of Resident #21's Quarterly MDS dated [DATE] revealed: BIMS score not completed. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #21's Care plan initiated on 02/02/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Huntington's Disease. admitted to Hospice. Goal: The resident's dignity and autonomy will be maintained at highest level through the review date. The resident's comfort will be maintained through the review date. Interventions: Keep the environment quiet and calm. Keep linens clean, dry and wrinkle free. Keep lighting low and familiar objects near. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #21's electronic Physicians Orders revealed no evidence of orders for hospice care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #21. Resident #35 Review of Resident #35's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses to include: Alzheimer's, depression, anxiety, and dementia. Record review of Resident #35's Significant Change MDS dated [DATE] revealed: BIMS score 05 which indicated severe cognitive impairment. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care. Record review of Resident #35's Care plan initiated on 04/20/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: ALZHEIMER'S DISEASE WITH LATE ONSET On hospice services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #35's electronic Physicians Orders revealed no evidence of orders for hospice care. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #35. Resident #34 Review of Resident #34's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses to include: heart failure, dementia, and back fracture. Record review of Resident #34's Quarterly MDS dated [DATE] revealed: BIMS score 06 which indicated severe cognitive impairment. Further review of MDS Section O Special Treatments, Procedures, and Programs revealed hospice care not claimed. Record review of Resident #34's Care plan initiated on 04/20/2024 revealed: Focus: The resident has a terminal prognosis r/t DX: Heart failure, unspecified. On Hospice Services. Goal: The resident will be free of depression and anxiety through the review date. The resident's comfort will be maintained through the review date. Interventions: Adjust provision of ADLS to compensate for resident's changing abilities. Encourage participation to the extent the resident wishes to participate. Encourage resident to express feelings, listen with non-judgmental acceptance, compassion. Encourage support system of family and friends. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Record review of Resident #34's electronic Physicians Orders revealed: ADMIT TO HOSPICE ., dated 11/29/2023. No evidence of a binder that contained the required hospice forms and documentation, that included the hospice plan of care and certificate of terminal illness for Resident #34. During an interview on 04/24/2024 at 10:46 AM, the DON stated that hospice communicated with the facility by writing orders. She stated she could not find the binder or any hospice information for any residents on hospice services. She stated that she did not know that hospice was supposed to provide information to the facility. During an interview on 04/24/24 at 10:49 AM, the RRN stated that she expected for facility to have hospice documentation either in a binder or in the medical record that included the hospice plan of care and certificate of terminal illness. She stated that facility did have hospice contact information and she called one of the hospice agencies and asked them to send over the binder with required information. She stated that she did not know why the facility did not have that information. She stated that the effect of not having the information could cause the resident to not get the care they needed because of not having continuity of care. During an interview on 04/24/24 at 11:16 AM, the SSD voiced that the 2 hospice charts at the nurses' station were for resident's that are no longer in the facility. She voiced that she did not find any hospice binders at the nurses' station for any of the current residents on hospice. Record review of the facility's Hospice Services Agreement dated effective November 27, 2023, between the nursing facility and Hospice revealed: .4. Hospice Services A. Hospice will: .6. Provide the facility with the following: 1. The most recent Hospice Plan of Care; 2. The Hospice election form and any advance directives specific to each Patient; 3. Physician certification and recertification of the Terminal , Illness specific to each Patient; 4. Names and contact information for Hospice personnel involved in the delivery of Hospice Services for each Patient; 5. Instructions on how to access Hospice's twenty-four hour on- call system; 6. Hospice medication information for each Patient; and 7. Hospice physician and Attending Physician, if any, orders for each Patient .8. Medical Records: a. Facility and Hospice will prepare and maintain medical records for each Hospice Patient. Such records will be prepared and maintained in conformity with federal and state law, rules, regulations, procedures, policies, guidelines, and generally accepted medical record practices . 48883

Based on interview and record review, the facility failed to ensure 4 of 5 (CNA-D, CNA-E, CNA-F, CNA-G) employees whose in-service records were reviewed had received the required minimum 12 hours annual in-service. The facility failed to provide the required annual performance care training to CNA-D, CNA-E, CNA-F, and CNA-G. This failure placed residents at risk for unmet needs due to untrained staff. Findings include: Record review of Personnel Files revealed: - Employee record for CNA-D revealed a hire date of 10/04/2021 and had no evidence of the required minimum 12 hours annual in-service. - Employee record for CNA-E revealed a hire date of 10/19/2021 and had no evidence of the required minimum 12 hours annual in-service. - Employee record for CNA-F revealed a hire date of 11/15/2021 and had no evidence of the required minimum 12 hours annual in-service. - Employee record for CNA-G revealed a hire date of 10/14/2021 and had no evidence of the required minimum 12 hours annual in-service. During an interview on 04/25/2024 at 2:00 PM, the DON stated she was responsible for nursing staff competencies and she had not performed any staff in-service competencies since she had been hired as DON, February 2024. She stated she had called the previous DON to see if she had the records of CNA required in-services, but she had no record. She stated she did not know how often staff in-service competencies should have been evaluated or their required annual training. The DON stated she was supposed to have monitored the CNA competency trainings. She stated the negative impact to residents could have been them not performing their duties correctly and possibly not giving them the proper care they deserved. She stated the failure was that she had not followed up with making sure the CNA's had all been trained correctly with documentation. The DON stated her expectations were for them to have had all of the competencies they needed and have the proper training and to take care of the residents as required. Record Review of the facility policy titled Nurse Aide Education, dated 08/16/17, revealed the following: - Competency will be evaluated initially and annually. - Facility will conduct a performance review of each nurse aide at least once every 12 months. 45732

Based observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts reviewed for label and storage of drugs and biologicals. The facility failed to ensure 1 medication cart (used by nurse for treatments performed on 200 and 400 halls was locked when unattended. This failure could place residents at risk of having access to unauthorized medications, wound care, and medical supplies leading to possible harm or drug diversions. Findings included: During an observation on 04/23/2024 at 6:23 p.m., an unlocked medication cart seen unattended by the nurses' station in between 200 and 400 halls with one resident approximately 6 feet away. There were medications including Nystatin (prescription anti-yeast) powders, Voltaren and hydrocortisone (over the counter topical) creams. Over the counter medication bottles including Aspirin, Tylenol, and colace (stool softener). Prescription medications including Zoloft (anti-depressant), trazodone (anti-depressant), Singulair (anti-inflammatory), Buspar (anti-anxiety), Baclofen (muscle relaxant), Keppra (anti-seizure), lactulose (anti-constipation), Sinemet (dopamine precursor), and Megace (appetite stimulant) in the cart. During an interview on 04/23/2024 at 6:25 p.m., RN A stated that she was responsible for the unlocked medication cart. She stated she had left it unlocked since counting medications during shift change. She stated that being nervous and distracted led to her not locking cart. RN A stated that she knew medication carts were to be locked when left unattended. She stated that she had not taken any in-services with the facility but had education through her agency as she was an agency nurse. She stated that the negative impact of leaving the cart unlocked could be possible adverse reactions leading to death if a resident were to take some medication out of cart. She stated the failure was the locking mechanism not being pushed in that would have locked the cart. During an interview on 04/23/2024 at 6:30 p.m. the DON stated medication carts should always be locked when unattended. She stated the negative impact would be residents could possibly have an allergic reaction and/or death if they took medications out of the medication cart. The DON stated all nursing staff should monitor the medication carts to make sure they are always locked. She stated she had not done any in-services herself, but had found in-services of June 2023, prior to her hire date. She stated the failure occurred when the nurse left the cart unlocked with her expectations being keeping all carts locked and to follow protocol. Record review of the facility policy titled Storage of Medications revised on 08/2020 revealed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications .Medication rooms, carts, and medication supplies are locked when they are not attended by persons with authorized access.

Based on interview and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries to 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to identify, assess and provide care for Resident #1's facility acquired unstageable pressure injury to her left heel. This deficient practice could place residents at risk for pressure injuries, pain, and a decline in health. Findings included: Record review of Resident #1's Face Sheet (Admission Record) dated 5/20/21 indicated an [AGE] year-old female admitted to the facility on [DATE]. Resident #1 medical history included [CONDITION(S)], Muscle Wasting, Dementia, Cognitive Communication Deficit, Muscle Weakness, Nutrition Deficit, and [CONDITION(S)]. There was no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of Resident #1's Significant Change in Status MDS dated [DATE] indicated Resident #1 had unclear speech but could sometimes be understood and could sometimes understand others. The Brief Interview for Mental Status (BIMS) was not conducted. A staff assessment for mental status indicated severely impaired cognitive skills for daily decision making. The assessment indicated Resident #1 did not reject care. The assessment indicated Resident #1 was totally dependent on one to two people for moving to and from lying position, turning side to side, and body positioning. The assessment indicated Resident #1 was totally dependent on one to two people for dressing, personal hygiene, eating, toileting and bathing. The assessment indicated Resident #1 was always incontinent of urine and bowel. The MDS dated [DATE] indicated no pressure ulcers for Resident #1. Record review of Resident #1's care plan indicated the following: Focus: The resident has a high risk for pressure injury, urinary and bowel incontinence, immobility, terminal prognosis and unavoidable pressure ulcer with a revision date of 5/19/21 Interventions: Administer treatments as ordered and monitor for effectiveness with an initiated date of 11/13/20. Focus: The resident has an Unstageable pressure injury to her inner left heel due to immobility and end of life process with an initiated date of 5/19/21. Interventions: Assess/record/monitor wound healing as needed measure length, width, and depth where possible. Assess document status of wound perimeter, wound bed and healing progress. Report improvements and declines to doctor with an initiated date of 5/19/21. Follow facility policies for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Braden Scale for Predicting Pressure Sore Risk, dated 3/26/21, indicated Resident #1 was at a high risk (score of 12) for developing a pressure injury. During an interview on 5/20/21 at 10:15 am with Hospice LVN D, she said that the wound on Resident #1's left heel was there for about a month or two and they had ordered interventions. She said the assessments were in the hospice reports and would provide for review. Review of Resident #1's Hospice Visit Note Reports indicated the following (of note, Hospice documentation was not available to the facility and was obtained from hospice at the request of the surveyor on 5/20/21): -4/8/21 blister to Heel was assessed by hospice for Resident #1. -5/4/21 Deep Tissue Injury to left heel. The report indicated an order to provide wound care 7x per week/PRN and Hospice 1x per week. Cleanse with NS, Pat Dry, Apply [MEDICATION(S)] ointment, and cover with foam dressing and heel protector. The wound to the left heel was measured at 4x3x0 cm as a suspected Deep Tissue Injury (DTI). Necrotic Tissue 75-<100%. The note was signed by the hospice nurse and LVN G. -5/11/21 Unstageable DTI to left heel onset date 4/16/21. -5/15/21 Received call that Resident #1 heel was not improving eschar non adherent to skin, scant excaudate, odor at close range. Order changed to cleanse with Dankins solution, pat dry, paint with iodine and cover with ABD pad and Kerlix every day. Wound measurement on 5/15/21 6x6.5x0.2 cm (increase in wound size), Necrotic tissues 76-100% (increase in necrotic tissue). -5/16/21 Wound to left heel continues to worsen and has foul odor. Doctor notified and waiting on orders. Record review of Nurse's Progress notes indicated no documentation from 4/8/21 through 5/11/21 related to the wound to Resident #1's left heel. Record review of Resident #1's Treatment Administration Record (TAR) and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's Treatment Administration Record (TAR) and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -Apply providone iodine to intact skin around decubitus to left heel until evaluated by hospice two times a day for wound healing with a start date of 5/15/21 and a discontinued date of 5/19/21 -Dakins (1/2 strength) solution apply to left inner heel topically every day for wound to left inner heel started 5/16/21 and discontinued 5/17/21 -Wound culture of left inner heel one time for wound infection for 5/18/21. -Clean left inner heel with normal saline or wound cleanser, pat dry with 4x4's apply calcium alginate silver to wound bed and cover with abd pad, wrap with [MEDICATION(S)] and secure with tape. Daily and as needed with a start date of 5/18/21. Record review of Nurse's Notes indicated the following: -5/12/21 LVN A documented Resident #1 has a decubitus on left inner heel need to contact hospice for wound care orders. -5/13/21 LVNA A documented Hospice called need to check wounds and report the status of condition of wounds are in at this moment. -5/15/21 CNA reported to RN B that Resident #1 had a pressure ulcer that is black with foul odor. RN B wrote a new order to treat intact skin around ulcer with iodine until hospice comes to assess and issues new orders. Measurements are 6cm in diameter to left inner heel. -5/15/21 DON wrote LVN C was notified of wound to residents left heel. Upon assessment measurements 6.0x6.0x0.2 cm. Wound black with minimal drainage with foul odor. DON instructed LVN C to follow up with hospice and doctor for further orders. Record review of the Facility Weekly Wound Assessments indicated the following: -4/6/21- No assessment for heel wound -4/13/21- No, was documented as an answer for does the resident have pressure, venous, arterial, diabetic, or surgical wound. -4/20/21- No, was documented as an answer for does the resident have pressure, venous, arterial, diabetic, or surgical wound. -4/27/21- Skin prep being applied to bilateral heels. No was documented as an answer for does the resident have pressure, venous, arterial, diabetic, or surgical wound. -5/4/21- No wound assessment for left heel. -5/11/21- No wound assessment for left heel. -5/15/21- Wound assessment indicated left inner heel unstageable pressure ulcer with measurements of 6x6x02 cm. Wound bed black without drainage. Mild odor. -5/18/21-Yes, was documented as an answer for does the resident have pressure, venous, arterial, diabetic, or surgical wound. Left inner heel was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Odor present. Current wound treatment to clean with wound cleanser or normal saline, pat dry with 4x4's apply calcium aginate silver and cover with abd pad and wrap with [MEDICATION(S)] and secure with [MEDICATION(S)]. Low air loss mattress. No was documented for the wound not being new. During an Observation of wound care on 5/19/21 at 4:33 pm, Resident #1 had an unstageable pressure ulcer to the inner aspect of the left heel. The left heel had eschar about a half dollar in size. There was no odor. The outer diameter of the wound had slough. During wound care there was minor moaning from Resident #1 even after being administered [MEDICATION(S)] for pain management related to the wound care of the left heel. During an interview with LVN A on 5/20/21 at 9:10 am, LVN A said he believed the wound on her heel had been there for a while but was unsure of the onset date. He said a CNA (couldn't remember name) reported the wound to him on 5/12/21 and then he reported the need for wound orders during shift change to the day nurse. He said the wound was elevated and left to air. He said he believed someone dropped the ball because it took about two days to get wound orders. He said that because they wore masks, the foot was covered with blankets, and the night shift does not do wound assessments the odor was not detected by him. He said when it was reported to him on 5/12/21 it was black about half dollar in diameter and had a foul odor. He said he there was no orders in place for the wound upon his discovery of the wound. During an interview with RN B on 5/20/21 at 9:32 am, he said that he initiated an order and contacted the doctor on 5/15/21. He said hospice had been contacted about a day ago but did not want to wait related to concerns of the wound getting worse. He said he was not aware of how long Resident #1 had the wound to her left heel. He said the wound was black and about half dollar size and was unstageable. He said there was no orders prior to him initiating wound orders for Resident #1. During an interview with LVN E on 5/20/21 at 1:20 pm, she said she was informed of the wound to Resident #1's left heel and left a message for hospice near the end of her shift on 5/12/21. She said she could not remember who she relieved on 5/12/21 because it was too long ago, and nurses rotate halls often at the facility. She said that whatever nurse was on duty that day for the hall completed the weekly skin assessment and there was not an assigned wound care nurse. She said she was not aware of Resident #1 having a wound to her heel prior or any orders for her heel prior to 5/12/21. During an interview with LVN G on 5/20/21 at 2:21 pm, she said she said she was familiar with Resident #1 and was not aware of a wound to Resident #1's left heel prior to 5/15/21. She said Hospice had not reported any skin breakdown or new orders for Resident #1. She said the wound on the heel on 5/15/21 was identified by the night nurses. During an interview with CNA H on 5/20/21 at 4:16 pm she said she had worked at the facility for a year and was familiar with Resident #1. She said she was not aware of a wound to the left heel of Resident #1. During an interview with CNA I on 5/20/21 at 4:19 pm, she said that she reported to LVN E and LVN G that she noted redness to the heels of Resident #1 back in April 2021 but did not know the exact date. She said since the staff rotate halls often, she thought it had been taken care of and was surprised how bad the heel had become when she reported the heel to the nurse on 5/11/21. She said she did not note it in the kiosk of her report to the nurse. During an interview with CNA J on 5/20/21 at 4:35 pm, she said that she can't recall the actual date, but she had reported to LVN E and LVN G that Resident #1 had redness to her heel. She said she reported the skin issue about a month ago. She said she thought the wound had been followed up on by the nurses. She said she did not note it in the kiosk of her report to the nurse. During an interview with the ADON and DON on 5/20/21 at 4:05 pm, The DON said that hospice should have notified the facility upon discovering a change to the Resident #1's skin. The DON said because hospice did bathing for the resident that a lot of opportunities for skin assessments were lost. The DON said he was not aware of the wound to Resident #1's left heel until he was made aware on 5/15/21. The ADON said that the facility monitored and treated wounds according to their policy for skin management and should have been followed regardless of the resident being on hospice care because ultimately the resident was the facility's responsibility. The DON said that the facility did not have the documenation from hospice and that they had requested the documentation after the surveyor had requested hospice documentation related to Resident #1's left heel wound. During an interview with the Administrator on 5/20/21 at 4:13 pm, he verified that his expectations were that the facility's policy for skin management be followed. Multiple attempts to contact Resident #1's physician were made but were unsuccessful prior to exit. The attempts were on 5/20/21 at 2:12 pm (was told to call back in about 20 minutes by the office secretary because the doctor was with a patient), 2:34 pm no answer, and 4:45 pm with no answer. Record review of an undated facility policy titled Skin Management System indicated the following: 1.A. Pressure Ulcers, Venous Ulcers and Arterial Ulcers, and surgical sites will be documented. Use one form per wound. Wound progress is to be documented each week with measurements and wound description. 2. Routine weekly checks will be completed on every resident; if skin is intact it will be noted as such. If a new pressure sore is noted, a progress record will be started. 4. CNA's will note any alteration in skin integrity during care in the POC and report to the Charge Nurse. Guidelines from the National Pressure Injury Advisory Panel, accessed on 5/24/21 at https://cdn.ymaws.com/npiap.com/resource/resmgr/online_store/npiap_pressure_injury_stages.pdf indicated: The updated staging system includes the following definitions: Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION(S)] separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions.

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services to prevent the development and promote the healing of pressure ulcers for 1 of 5 residents reviewed for pressure ulcers. (Resident #3). a) For two days the facility failed to inform the physician of wound culture results indicating the organism present in resident #3's pressure sore was resistant to one of the prescribed antibiotics b) Staff failed to notify the treatment nurse when Resident #3's dressing came off on 09/21/17. c) The facility failed to consistently use pressure relieving devices while Resident #3 was in her Geri-chair. d) The facility failed to initiate a care plan for Resident #3's pressure ulcer from 07/2017 till 09/2017. The facility failed to prevent Resident #3 from developing an un-stageable pressure ulcer on the coccyx on 09/21/17. These deficient practices resulted in an Immediate Jeopardy (IJ) on 09/21/17. While the IJ was removed on 09/22/17 the facility remained out of compliance at a level of Actual Harm at a Pattern that was not IJ because the facility had not had time to implement and monitor policies and procedures. These failures resulted in pressure ulcer development and deterioration for Resident #3 and could place the 4 other residents with pressure ulcers at risk for developing new pressure ulcers or worsening of existing pressure ulcers. Findings included: Review of Resident #3's Resident Face Sheet dated 09/22/17 indicated the resident was admitted on [DATE]. She was admitted with [DIAGNOSES REDACTED]. Review of Resident #3's Care Plan dated 01/29/16 indicated the following: - Resident #3 was at risk for skin breakdown due to history of pressure ulcers, decreased mobility, incontinence and nutrition. - Goals were: Resident #3 will be observed, monitored and assess for skin break down through next review date. - Approaches were: Follow facility policies/protocols for the prevention/treatment of skin breakdown. Notify Medical Director and responsible party of any changes in condition. Observe skin when providing care for redness, open and notify nurse. Provide assistance for toileting/incontinence checks every 2 hours and as needed. Provide peri-care as needed Review of Resident #3's Annual Minimum Data Set ((MDS) dated [DATE], indicated a Brief Interview for Mental Status (BIMS) score of 0 ( a score of 0-7 indicating severe cognitive impairment ). Resident #3 required extensive two person assistance with bed mobility, dressing, and personal hygiene and was dependent on staff for bathing. Resident #3 had functional range of motion impairment on both sides of her upper and lower extremities. The resident was frequently incontinent of bowel and had an indwelling urinary catheter. Resident #3 was identified with Stage III pressure ulcer (size and location were not documented). Full thickness loss of skin, in which adipose fat is viable in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible, obtained on 09/27/17 from National Pressure Ulcer Advisory Panel. (Note: A care plan should have been initiated or updated that reflects pressure ulcers developing). - Review of Resident #3's weekly skin assessment dated [DATE] indicated the following: Stage III pressure ulcer to the coccyx 3.3 cm (centimeter) x 2.4 cm yellow slough noted to wound clear drainage with zero odor. Record Review of Resident #3's resident Progress notes (nursing) documented the following in part: - 09/10/17 at 5:13 p.m. Resident continues with wound to inner buttocks wound bed green and dark gray around edges has strong foul odor treatment done this afternoon has moderate amount of dark yellow greenish drainage. -09/12/17 at 3:31 p.m. Resident continues with wound to sacral area wound bed has strong foul odor treatment done this shift as order states has moderate amount of purulent drainage. Resident #3's physician came in this afternoon and wanted to see the wound and would get a culture tomorrow after the wound was clean and redressed as resident had a large soft bowel movement had compromised the wound culture. Review of Resident #3's Physician's telephone orders dated 09/12/17 at 3:51 p.m. indicated: Wound infection to coccyx-culture wound. Record Review of Resident #3's resident Progress notes (nursing) documented the following in part: -09/12/17 at 5:36 p.m. Resident #3's Physician was contacted due to increase redness surrounding pressure ulcer to coccyx and light reddened raised area to left buttock up towards hip; yellow slough to wound bed has changed to a olive green color with raised macerated wound edges. Physician stated to continue wound care order until culture returns and gave new orders for medication as follows: Keflex 500 mg by mouth three times daily for 10 days; [MEDICATION NAME] 500mg by mouth three times daily for 10 days; Acidophilus 1 capsule by mouth everyday due to wound infection. Culture obtained. -09/13/17 at 1:17 p.m. Continue with wound to sacral area dressing clean dry and intact. Wound culture pending continues with foul odor changed as ordered. -09/13/17 at 2:40 p.m. Wound culture pending. -09/14/17 at 10:54 a.m. continues with Keflex, [MEDICATION NAME] and acidophilus for treatment of [REDACTED]. -09/14/17 at 7:35 p.m. Contacted Resident #3's physician after meeting with wound care representative discussed wound care recommendations and physician gave order to follow those recommendations: pressure ulcer coccyx: Clean with acetic acid, pat dry, apply skin prep to surrounding skin, apply collagen powder to wound bed, apply maxsorb silver over wound bed and cover with absorbent dressing every day and as needed until resolved. -09/15/17 at 2:42 a.m. Day 3 of 10 for [MEDICATION NAME] and Keflex. No signs of adverse reactions. Results for wound culture pending. -09/15/17 at 11:18 a.m. Resident continues with keflex, [MEDICATION NAME] and acidophilus for treatment of [REDACTED]. -09/16/17 at 1:22 a.m. New order for wound care to coccyx. day 3 of 10 for [MEDICATION NAME] and Keflex. No signs of adverse reactions. Results of wound culture pending. -09/17/17 at 4:55 a.m. Wound culture results received and faxed to physician. -09/18/17 at 4:02 a.m. Continued on Keflex and [MEDICATION NAME] day 6 of 10, no adverse reaction noted. Continued with wound care treatment to coccyx. -09/19/17 at 3:22 p.m. Updated physician due to worsening wound, evidenced by increased wound measurements and slough present on wound bed; contacted physician advised of current wound status and gave verbal order for referral to Medical Center Hospital Wound Care Center. Review of Residents Wound Assessment Record dated: 07/28/17-A Stage III pressure ulcer to the coccyx 3.5 x 2 cm yellow slough with pink wound bed 09/1/17-a Stage III pressure ulcer to the coccyx 3.3 x 2.4 cm yellow slough with clear drainage zero odor. 09/13/17- a Stage III pressure ulcer to the coccyx 4.8 x 2.8 x 1.6 cm yellow olive green slough noted to wound bed and slightly macerated wound edges. Slight odor during wound care. (indicates the wound is deteriorating) 09/21/17- An Unstageable pressure ulcer to coccyx 4.4 x 3.4 x 1.2 cm with undermining 0.8 centimeters (cm) at 3 o'clock to 1.5 cm at 11 o'clock wound bed with olive green slough covering entire wound bed. Zero odor, wound edges slightly macerated from 9 o'clock to 4 o'clock reddened edges from 5 o'clock to 7 o'clock. Dark pink periwound. (Unstageable Pressure Injury: Full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Http://www.npaup.org/resources/educational-and-clinincal-resources/npaup-pressure-injury Review of Resident #3's weekly skin assessment dated [DATE] indicated the following: Stage III pressure ulcer to the coccyx 3.3 cm (centimeter) x 2.4 cm yellow slough noted to wound clear drainage with zero odor. Review of Medication Flowsheet orders dated 09/12/2017 acidophilis (lactobacillus acidophilus) 1 capsule by mouth once daily. [MEDICATION NAME] 500mg 1 tablet by mouth three times daily. Keflex 500mg 1 capsule by mouth three times daily for wound infection Review of Resident #3's weekly Skin assessment dated [DATE] indicated the following: Stage III pressure ulcer to the coccyx 4.8 x 2.8 x 1.6 yellow olive green slough noted to wound bed and slightly macerated wound edges. Slight odor during wound care. Review of Resident #3's wound culture results dated 09/17/17 documented: 1. Organism #1 Proteus Mirabilis (bacteria); 2. Organism #2 [MEDICATION NAME] Faecalis (bacteria). Organism Susceptibility: Antibiotics - [MEDICATION NAME] - Resistant. Accessed 09/29/17 https://www.drugs.com/answers/what-is-the-difference-between-[MEDICATION NAME]-and- 7.html Both [MEDICATION NAME] and [MEDICATION NAME] are first generation cephalosporins with coverage mainly against gram-positive bacteria. They are time-dependent bactericidal antibiotics that work by disrupting the bacterial cell membrane. Both have similar antibacterial coverage with the only real difference being that [MEDICATION NAME] is available orally where as [MEDICATION NAME] is only available as injection. Review of Resident #3's Nurses Notes dated 9/17/17 at 4:55 a.m. indicated: Resident #3's physician was faxed results of the wound culture. (There was no documentation found to indicate any attempts were made to contact resident #3's physician via telephone) During Interview with LVN Q on 09/22/17 at 10:45 a.m. Said she was the nurse who called the wound culture results to Resident #3's physician on 09/19/17. She said she went into work and the night nurse told her she faxed the wound culture results on Saturday. LVN Q said she asked night nurse why she didn't call the physician. During a telephone interview on 9/22/17 at 10:20 a.m. with Resident #3's Physician/facility Medical Director regarding Resident #3. She said all facility staff know she is available and can be reached on weekends at any hour of the day. She said the nurse that received the wound culture on 09/17/17 should have called her to get order to change antibiotics that would cover wound infection. Review of Residents #3's Nurses Notes dated 9/19/17 at 6:00 p.m. documented: physician called (regarding 09/16/17 fax) and new order was received for: [MEDICATION NAME] 500mg Three times daily (antibiotic) for 2 weeks for [DIAGNOSES REDACTED]. Review of Resident #3's Braden Assessment Scale dated 09/19/17 documented as score of 14 ( a score of 14-18 indicates moderate risk). Record review of Resident #3's flow sheet dated 08/30/17 indicated in part: - Pressure relieving gel pad to wheelchair every shift 11/21/15 - open ended. During an observation on 09/18/2017 at 4:00 p.m. Certified Nurse Aide (CNA) L and CNA M prepared to transfer Resident #3 from her bed to the Geri-chair. There was no gel pad found or used in the resident's Geri-chair. During an observation on 09/19/17 at 4:40 p.m. Resident #3 was up in her Geri-chair in the hallway. CNA E checked to see if the resident was sitting on top of the gel pad. CNA E reported no pad was found under the resident. During an observation and interview on 09/20/17 at 10:05 a.m. Resident#3 was being transferred from her Geri-chair to her bed and there was no gel pad found on the resident's Geri-chair. During interview on 09/20/17 at 10:05 a.m. CNA N said Resident #3 used a gel pad while up in her geri-chair but she did not have one in her room. Resident #3's care Plan dated 09/20/17 documented Resident #3 had Pressure Ulcer: Potential or actual pressure ulcer or altered skin integrity related to: as evidenced by: Stage III Pressure Ulcer to coccyx measurements 4.0 cm x 3.3 cm x 1.0 cm. (Care Plan was not updated until after surveyor intervention) Review of Resident #3's weekly Skin assessment dated [DATE] indicated the following: Unstageable pressure ulcer to coccyx 4.4 cm x 3.4 cm x 1.2 cm with undermining 0.8 CM at 3 o'clock to 1.5 cm at 11 o'clock wound bed with olive green slough covering entire wound bed. Zero odor, wound edges slightly macerated from 9 o'clock to 4 o'clock reddened edges from 5 o'clock to 7 o'clock. Dark pink peri-wound. Review of Resident #3's care plan dated 09/21/17 documented Resident #3 had Pressure Ulcer: -Actual pressure ulcer as evidenced by Unstageable pressure ulcer to coccyx. -Goal: Pressure ulcer will show signs of healing through next review date. Approach: Use Geri chair with gel cushion. During an observation on 09/21/17 at 10:10 a.m. the treatment nurse performed wound care to Resident #3's coccyx pressure ulcer. There was no dressing found on the wound and yellow drainage from the wound was noted on the draw sheet. The wound edges were noted to be red and raised with macerated edges. The wound bed with dark olive green slough covering entire wound center. The nurse performed the wound care and applied a new dressing as the orders indicated there should always be one in place. During an interview on 09/21/2017 at 3:33 p.m. CNA M said he had assisted with getting Resident #3 out of bed this morning. CNA M said he had noticed the dressing was not on the wound but failed to notify the nurse and proceeded to get the resident out of bed. During an interview on 9/21/17 at 5:00 p.m. the Treatment Nurse/LVN said the facility was getting Resident #3 an air mattress tonight and had up-staged Resident #3's pressure ulcer to an Unstageable. During interview on 09/22/17 at 10:55 a.m. MDS Coordinator said the care plan should have been initiated sooner than 09/20/17, it should have been initiated when the pressure ulcer was originally documented as a Stage III pressure ulcer on 06/16/17 Review of the facility's September 2013 Policy and Procedure on Pressure Ulcer Risk Assessment documented, in part: Purpose: The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation: Review the resident's care plan to assess for any special needs of the resident. Once a pressure ulcer develops, it can be extremely difficult to heal. Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor. Assessment: Skin Assessment: Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. Review of the facility's September 2013 policy and procedure on Prevention of Pressure Ulcers documented, in part: Purpose: The purpose of this procedure is to provide information regarding identification of pressure ulcer risk factors and interventions for specific risk factors. General Guidelines: Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area and subsequent destruction of tissue. Use foam, gel or air cushion as indicated to relieve pressure. Review of the facility's March 2014 policy and procedure on Pressure Ulcers/Skin Breakdown documented in part: Assessment and Recognition: The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue; b. The physician will assist the staff to determine etiology and characteristics (necrotic tissue, status of wound bed, etc.) of the skin alteration. Cause Identification 1. the physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbities such as diabetes or [MEDICAL CONDITION], overall medical instability, cancer [MEDICAL CONDITION] causing a catabolic state, and macerated or friable skin. 2. The physician will help clarify relevant medical issues; for example, whether there is a soft tissue infection or just wound colonization, whether the wound has necrotic tissue, the impact of comorbid conditions on wound healing, etc. Treatment/Management 1. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc. During an interview on 09/21/17 at 6:00 p.m., the Administrator was informed the surveyors had identified an Immediate Jeopardy. During an interview on 09/22/2017 at 2:00 p.m. the Regional Nurse Consultant said the failure to notify physician in a timely manner regarding wound culture results on Resident #3 was caused by the fact that it was an agency nurse working that particular day. The Regional Nurse Consultant acknowledged yes, it should have been called in. The facility's Plan of Removal of Immediate Jeopardy was accepted on 09/22/17 at 2:45 p.m. and included the following: Plan of Removal of IJ at(NAME)Nursing and Rehabilitation Areas of Concern: Multi System Failure Related to Wounds Identification of Pressure Sores The DON, Treatment Nurse, was re-educated on Skin Monitoring System Guideline. All residents with wounds were reviewed. Anyone with worsening wounds were re-assessed for dietary and preventive interventions. There were no wounds that were identified as worsening per our review. The physician was notified of any worsening wounds. The Regional Nurse consultant reviewed the current physician orders [REDACTED]. The IDT reviewed the plan of care and updated as indicated. Date of Completion: 09/21/17. Staff education related to pressure sores The DON/designee in-serviced all the nursing staff on the prevention of pressure sores, removing wound dressings, reporting when any residents dressing has come off, turning and positioning of high-risk residents, identification and reporting any skin change noted during care, CNA care plan book, and Nurse to CNA shift report. The CNAs will have access to know who has wounds and dressings through the CNA careplan binder. The licensed nurses were also in-serviced on the proper documentation requirements related to a pressure sore and notification of the physician, follow up on notification if no response within 48 hrs. Education on notifying resident/responsible party when a resident has any change in condition. Completed on 09/21/17. The Regional Nurse Consultant in-serviced the Treatment Nurse, DON, ADON, on Guidelines for Skin Monitoring System. Completed on 09/21/17. The Regional Nurse Consultant also evaluated the pressure relief interventions to include cushions and mattresses. Completed 09/21/17. Monitoring of Pressure Sores Started 09/21/17. The DON designee will do random check on residents with pressure sores at least once a week to ensure that the intervention put in place are effective. The DON/ designee will then take the Wound Care Log and sign that she completed an audit on sample residents with wounds. The DON/ designee will review consultant reports in morning clinical meeting to ensure an intervention was added if a change has occurred if no interventions were initiated the IDT team will review and implement interventions. The DON/ designee will document on the clinical meeting form that recommendations were reviewed. In-service on 09/21/17. Following this evaluation, the DON/ designee will contact the physician to discuss possible treatment changes and order/provide alternative interventions if indicated. All consultant reports will be reviewed in the weekly clinical meeting. The DON/ designee will utilize the Weekly Wound Tracking form to document the assessment and interventions. This form will be presented to the QA & A. Committee at least monthly for review and recommendations. Started 09/21/17 The Certified Nursing Assistants (CNA) were in-serviced on 09/21/17 about the Continuous Pressure Ulcer Prevention which provide the CNA's with a knowledge to document any noted skin change for a resident that they identify during routine daily resident care. The CNA's were all given information on the resident CNA care plans that are readily available at the nurses' station on 09/21/17. Monthly and ongoing The facility will ensure that the Daily Clinical Meeting occurs to review all residents with a change of condition including pressure sores. Refer to attached Daily Clinical Meeting Guidelines and the form which is attached. The Daily Clinical Meeting Form will be submitted to the QA & A Committee for review and intervention as the team deems necessary. No later than 09/21/17. American Medical Technology (AMT) will conduct monthly visits that include checking the pressure sores with the Treatment nurse and making recommendations for alternative treatments if necessary. On-Going Skin Management System Resident will have a skin check and a Braden Scale completed on admission/readmission (within 4 hours) by the charge nurse who is completing the admission. Any identified pressure sore or other skin problem will be reported to the physician to obtain treatment orders and notify the resident/responsible party. The charge nurse will document all findings on the admission paperwork and the 24 hour Report. Starting 09/21/17 All new resident admissions/readmissions will be reviewed in the daily Clinical Meeting. The DON/designee will check the newly admitted /readmitted resident's skin within 24 hours of admission or on Monday following a weekend admission to ensure all skin problems and interventions are identified and appropriate. On-going All residents that are admitted /readmitted will have a Braden scale completed on admission and then for 3 consecutive weeks for a total of 4 weeks to establish a baseline. In addition to the Braden Scale, the Treatment Nurse will complete the Skin Risk Evaluation and Interventions form for all residents who have a Braden Scale of 18 or less and/or the resident has a wound. (Refer to attached Skin Risk Evaluation and Intervention form attached). The resident plan of care related to an identified wound and/or a resident that is high risk for breakdown will be initiated with the interventions portion of the form. DON/ designee will review care plans for completion and accuracy at weekly Quality of Care meeting. The treatment nurse will conduct weekly head to toe skin assessments on every resident in the facility. The treatment nurse will report any newly identified skin problem to the DON/ designee and the DON/ designee will evaluate the skin problem. The treatment nurse or DON will contact the physician for treatment orders and will notify the resident/responsible party of the same. The treatment nurse will initiate the treatment, note the skin problems and new order on the 24-Hour report and document all of the above in the nurses' progress notes and update CNA weekly with any changes. The ordered treatment will be noted on the current treatment documentation form. The Nurse Management team will check that all of the above are completed in the daily Clinical Meeting following the initiation of the above. On-going The treatment nurse will be responsible for providing the treatments for all residents as ordered by the physician Monday through Friday and/or as scheduled to work as the treatment nurse. When the treatment nurse is not available to work as the treatment nurse, the Charge nurse for each hall will be responsible for providing the physician ordered treatments to the residents on the assigned hall. Charge nurses will be in serviced on best practice related to wound care and nursing proficiencies will be completed on wound care. The DON and/or ADON will monitor the completion of the treatments by the charge nurse by checking the dressings to ensure they were changed, intact and interventions initiated according to the physician orders. Any problems noted by the DON and/or ADON with the treatments will be addressed immediately with the Charge Nurse to ensure that all residents receive the ordered treatments. Start 09/21/17 and on-going The Nurse Management Team will meet every week to have the Weekly Quality of Care Review. (Refer to the attached guideline and form). The Nurse Management Team will review all residents identified with new pressure or worsening pressure sores in the last week to ensure that all appropriate treatments and pressure prevention measures are in place and completed as ordered. Action Plan verification activities were conducted on 09/22/17 which included the following activities: Review of all in-service documentation, Review of 100% skin evaluations/Braden scales, skin checks and interviews with charge Nurses and CNAs to confirm nursing knowledge of processes identified in action plan. During an interview on 09/22/17 at 4:19 p.m. CNA L they had been in-serviced yesterday regarding pressure ulcers and the CNA care plan. CNA L said if she noticed a wound dressing had come undone or had fallen off she would immediately report it to the nurse. CNA L said they were supposed to reposition the residents every 2 hours to prevent pressure sores. CNA L said they also now had a CNA care plan that was located at the nurse's station. CNA L said the care plan indicated which residents had pressure ulcers and what their plan of care was. During an interview on 09/22/17 at 4:24 p.m. CNA O said she had been in-serviced yesterday on the CNA care plan and what to do in case a residents dressing comes off. CNA O said the care plan was kept at the nurse's station by their flow books. CNA O said the care plan indicated the care each resident required. CNA O said if a resident's wound dressing came off she would immediately report it to the nurse. CNA O said she would also reposition the residents every 2 hours. During an interview on 09/22/17 at 4:35 p.m. CNA K said she had received training on reporting immediately to the nurse if the wound dressing had come off. CNA K said she had been trained regarding the CNA care plan located at the nurse's station. CNA K said the care plan indicated the care each resident required. During an interview on 09/22/17 at 4:52 p.m. CNA I said they had been in-serviced on wounds like if the dressing came undone and repositioning the residents every 2 hours. CNA I said if there were any issues with the dressing they were not to touch it but to notify the nurse immediately. CNA I said they also now had a CNA care plan that indicated each resident's individual needs. During an interview on 09/22/17 at 5:01 p.m. CNA H said she had been trained on how to notify the nurse right away if the wound dressing came undone. CNA H said they also had a CNA care plan that indicated if the residents had wounds and their activities of daily living (ADL) care. During an interview on 09/22/17 at 5:04 p.m. LVN Q said she had been trained regarding wounds, pressure ulcers, dressings and communication with the CNAs. During an interview on 09/22/17 at 5:14 p.m. CNA C said she had been in-serviced on wounds like if the dressing came undone to report it to the nurse right away. CNA C said they also got trained regarding the CNA care plan which is kept at the nurse's station. CNA C said the care plan indicated what kind of care each resident received like how many staff to transfer, ambulatory and wounds. The Administrator was notified that the IJ was removed prior to exit on 09/22/15 at 2:45 p.m. The facility remained out of compliance at a scope of security level of Actual Harm that is not immediate jeopardy at a Pattern that was not IJ because the facility had not had time to implement and monitor their plan for effectiveness. Review of the form CMS 672 Resident Census and Conditions of Residents completed by the DON on 09/19/17 documented there were 5 residents having pressure ulcers.